Healthcare Provider Details

I. General information

NPI: 1194226746
Provider Name (Legal Business Name): BROOKE ALEXANDRA CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15339 SATICOY ST
VAN NUYS CA
91406-3345
US

IV. Provider business mailing address

12099 W WASHINGTON BLVD
LOS ANGELES CA
90066-5882
US

V. Phone/Fax

Practice location:
  • Phone: 818-267-2681
  • Fax:
Mailing address:
  • Phone: 310-751-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0003724
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBC0003724
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT129709
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: