Healthcare Provider Details

I. General information

NPI: 1003587122
Provider Name (Legal Business Name): BROOKE HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 W DAKIN ST APT 1W
CHICAGO IL
60613-2991
US

IV. Provider business mailing address

1024 W DAKIN ST APT 1W
CHICAGO IL
60613-2991
US

V. Phone/Fax

Practice location:
  • Phone: 916-765-6942
  • Fax:
Mailing address:
  • Phone: 916-765-6942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: