Healthcare Provider Details

I. General information

NPI: 1871788752
Provider Name (Legal Business Name): BRIAN FREDERICK BROOK LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57418 CR 681 SUITE B
HARTFORD MI
49057
US

IV. Provider business mailing address

PO BOX 249 801 HAZEN STREET SUITE C
PAW PAW MI
49079-0249
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-6261
  • Fax: 269-621-6044
Mailing address:
  • Phone: 269-657-5574
  • Fax: 269-657-3474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801060843
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: