Provider Demographics
NPI:1932713385
Name:POWELL, BROOKE NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:POWELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 GLENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-1509
Mailing Address - Country:US
Mailing Address - Phone:817-368-9679
Mailing Address - Fax:
Practice Address - Street 1:1804 GLENMORE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-1509
Practice Address - Country:US
Practice Address - Phone:817-368-9679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72602101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health