Healthcare Provider Details

I. General information

NPI: 1326250978
Provider Name (Legal Business Name): BEVERLY DAWN BROOKS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 05/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 VILLAGE TRCE NE BLDG 18 PAPER MILL VILLAGE OFFICE PARK
MARIETTA GA
30067-4081
US

IV. Provider business mailing address

660 VILLAGE TRCE NE BLDG 18 PAPER MILL VILLAGE OFFICE PARK
MARIETTA GA
30067-4081
US

V. Phone/Fax

Practice location:
  • Phone: 678-267-6054
  • Fax:
Mailing address:
  • Phone: 678-267-6054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY002831
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1844
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY002831
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1844
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberPSY002831
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1844
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: