Provider Demographics
NPI:1811596687
Name:LINES, BROOKLYN JO (LSW)
Entity type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:JO
Last Name:LINES
Suffix:
Gender:
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-3442
Mailing Address - Country:US
Mailing Address - Phone:765-573-5055
Mailing Address - Fax:
Practice Address - Street 1:1331 W 35TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-3442
Practice Address - Country:US
Practice Address - Phone:765-573-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-20-140266106S00000X
IN99128789A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician