=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356492128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL E. BROOKER, ED.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 181 14TH ST NE SUITE 450
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-3674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-873-6178
-----------------------------------------------------
Fax | 404-873-0342
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 181 14TH ST NE SUITE 450
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-3674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-873-6178
-----------------------------------------------------
Fax | 404-873-0342
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. RUSSELL EDWIN BROOKER
-----------------------------------------------------
Credential | ED.D.
-----------------------------------------------------
Telephone | 404-873-6178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 360
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------