Healthcare Provider Details

I. General information

NPI: 1780776856
Provider Name (Legal Business Name): RONALD E. BROOKS JR. ED.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 N MAIN ST
DOYLESTOWN PA
18901-3715
US

IV. Provider business mailing address

354 N MAIN ST
DOYLESTOWN PA
18901-3715
US

V. Phone/Fax

Practice location:
  • Phone: 215-340-0143
  • Fax:
Mailing address:
  • Phone: 215-340-0143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS004407-L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier101667583 0001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: