Healthcare Provider Details

I. General information

NPI: 1053736827
Provider Name (Legal Business Name): STEPHANIE RENEE BROOKS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 POPE AVE
FORT LEAVENWORTH KS
66027-2332
US

IV. Provider business mailing address

550 POPE AVE
FORT LEAVENWORTH KS
66027-2332
US

V. Phone/Fax

Practice location:
  • Phone: 913-684-6771
  • Fax:
Mailing address:
  • Phone: 913-684-6771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2015027344
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: