Healthcare Provider Details

I. General information

NPI: 1427521277
Provider Name (Legal Business Name): IVANA DJORDJEVIC BROOKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IVANA DJORDJEVIC BROOKS

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1666 HIGHWAY 160 W
FORT MILL SC
29708-8024
US

IV. Provider business mailing address

725 RIDGELINE DR UNIT 227
FORT MILL SC
29708-9515
US

V. Phone/Fax

Practice location:
  • Phone: 512-615-5186
  • Fax:
Mailing address:
  • Phone: 757-343-6803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1898
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: