Provider Demographics
NPI:1881250280
Name:GOLD, BROOKE ELAINE (BCBA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELAINE
Last Name:GOLD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ELAINE
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10175 FORTUNE PKWY UNIT 903
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6755
Mailing Address - Country:US
Mailing Address - Phone:904-538-0713
Mailing Address - Fax:
Practice Address - Street 1:600 E OGLETHORPE HWY STE B
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2988
Practice Address - Country:US
Practice Address - Phone:407-670-9047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBACB479636103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst