Healthcare Provider Details

I. General information

NPI: 1225142482
Provider Name (Legal Business Name): J. ANNETTE BROOKS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE 116
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1704 CAMINO DE LA SIERRA NE
ALBUQUERQUE NM
87112-4939
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-5438
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number728
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2313
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: