Healthcare Provider Details

I. General information

NPI: 1083816300
Provider Name (Legal Business Name): KELLY ANNETTE BROOKS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 PENNSYLVANIA ST NE
ALBUQUERQUE NM
87110-7410
US

IV. Provider business mailing address

808 MANZANO ST NE
ALBUQUERQUE NM
87110-6306
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-9536
  • Fax:
Mailing address:
  • Phone: 505-550-9536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0099101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: