Healthcare Provider Details

I. General information

NPI: 1922812213
Provider Name (Legal Business Name): BROOKE BRACKETT M.ED, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5127 N WOLCOTT AVE APT 1S
CHICAGO IL
60640-2657
US

IV. Provider business mailing address

5127 N WOLCOTT AVE APT 1S
CHICAGO IL
60640-2657
US

V. Phone/Fax

Practice location:
  • Phone: 815-978-9669
  • Fax:
Mailing address:
  • Phone: 815-978-9669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.016586
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.016586
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.016586
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: