Provider Demographics
NPI:1881169589
Name:GARREN, BROOKE A
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:GARREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E LINCOLN HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1993
Mailing Address - Country:US
Mailing Address - Phone:779-707-3717
Mailing Address - Fax:
Practice Address - Street 1:400 E LINCOLN HWY STE 102
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1993
Practice Address - Country:US
Practice Address - Phone:779-707-3717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IL1490231691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician