MEDICARE: BROOKE ALEXANDRA GONZALES BT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1265288005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE ALEXANDRA GONZALES BT

Provider Business Mailing Address
First Line	:	1430 LILAC AVE
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23325-3814
Country	:	US
Telephone Number	:	757-338-5439
Fax Number	:

Provider Business Practice Location Address
First Line	:	5621 TIDEWATER DR
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23509-1497
Country	:	US
Telephone Number	:	757-416-5290
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2024
Last Update Date	:	04/24/2024

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