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General NPI Number Information
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NPI Number | 1255807210
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Entity Type | Individual
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Provider Name | BROOKE EARIN SJOSTROM MS
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Gender | Female
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Dates
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Enumeration Date | 10/17/2018
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Last Update Date | 10/17/2018
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Provider Practice Location Address
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Address Line | 250 NORTHWEST BLVD STE 101A
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2971
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Country | US
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Telephone | 208-691-1174
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Fax | 208-247-8513
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Provider Business Mailing Address
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Address Line | PO BOX 129
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-0129
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Country | US
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Telephone | 208-691-1174
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Fax | 208-247-8513
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LH00007832
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LCPC-4347
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License Number State | ID
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