Healthcare Provider Details

I. General information

NPI: 1669745675
Provider Name (Legal Business Name): WALTER BROOKS PHD, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 05/29/2023
Certification Date: 05/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 FORSYTH ST SW
ATLANTA GA
30303-3634
US

IV. Provider business mailing address

PO BOX 55469
ATLANTA GA
30308-5469
US

V. Phone/Fax

Practice location:
  • Phone: 404-523-4599
  • Fax: 404-586-0645
Mailing address:
  • Phone: 404-523-4599
  • Fax: 404-586-0645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1091587
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberLPC003956
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC003956
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: