Healthcare Provider Details

I. General information

NPI: 1497165476
Provider Name (Legal Business Name): JEANNINE ANAHI BROOKS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 NEW DORP LN
STATEN ISLAND NY
10306-4902
US

IV. Provider business mailing address

475 SEAVIEW AVE STATEN ISLAND
STATEN ISLAND NY
10305-3436
US

V. Phone/Fax

Practice location:
  • Phone: 718-987-0128
  • Fax: 718-987-0223
Mailing address:
  • Phone: 718-987-0128
  • Fax: 718-987-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number063246-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number082604-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: