Provider Demographics
NPI:1952720286
Name:BROOKS, MICHELE (BCABA)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5414 GALLEY CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-3305
Mailing Address - Country:US
Mailing Address - Phone:401-523-3180
Mailing Address - Fax:
Practice Address - Street 1:1219 SKYLARK DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33327-2380
Practice Address - Country:US
Practice Address - Phone:401-523-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0-14-5899103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst