MEDICARE: CARLY CHRISTINE BROOKS MA, LLPC

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	101YP2500X	Professional Counselor	6401019347	MI

General Provider Information

NPI Number	:	1629643119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY CHRISTINE BROOKS MA, LLPC

Provider Business Mailing Address
First Line	:	357 WASHINGTON ST SE APT 1
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4338
Country	:	US
Telephone Number	:	925-989-7631
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 EASTERN AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-3632
Country	:	US
Telephone Number	:	616-805-9276
Fax Number	:	616-326-2905

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

Provider Enumeration Date	:	05/26/2021
Last Update Date	:	05/26/2021

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