Provider Demographics
NPI:1952134686
Name:PREMO, BROOKE (ALC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:PREMO
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 ALFORD AVE
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-1915
Mailing Address - Country:US
Mailing Address - Phone:205-765-5777
Mailing Address - Fax:
Practice Address - Street 1:1318 ALFORD AVE STE 101
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35226-3167
Practice Address - Country:US
Practice Address - Phone:205-784-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04983101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health