=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205849692
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLA A BROOKE L.M.H.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 904 E 25TH ST
-----------------------------------------------------
City | KEARNEY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68847-4604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-234-9982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3505 3RD AVE
-----------------------------------------------------
City | KEARNEY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68845-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-234-3135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 1655
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------