Healthcare Provider Details

I. General information

NPI: 1043374788
Provider Name (Legal Business Name): PHYLLIS BROOKS LICSW LIC 1043921
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MAIN STREET
WENHAM MA
01984
US

IV. Provider business mailing address

ENVISION HEALTH AND HEALING 225 MAIN STREET
WENHAM MA
01984
US

V. Phone/Fax

Practice location:
  • Phone: 978-468-0005
  • Fax: 978-774-9218
Mailing address:
  • Phone: 978-468-0005
  • Fax: 978-774-9218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW 104392-1
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: