=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437577616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REBECCA PRATHER BROOKS, PHD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2014
-----------------------------------------------------
Last Update Date | 11/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2746 GULF BREEZE PKWY SUITE B
-----------------------------------------------------
City | GULF BREEZE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32563-3091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-932-2746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2746 GULF BREEZE PKWY SUITE B
-----------------------------------------------------
City | GULF BREEZE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32563-3091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-932-2746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. REBECCA PRATHER BROOKS
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 816-309-5211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | PY01839
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------