Provider Demographics
NPI:1053795989
Name:BROOKS, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1654
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-1654
Mailing Address - Country:US
Mailing Address - Phone:678-386-1895
Mailing Address - Fax:678-623-8300
Practice Address - Street 1:220 W CROGAN ST
Practice Address - Street 2:STE A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3238
Practice Address - Country:US
Practice Address - Phone:678-386-1895
Practice Address - Fax:678-623-8300
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004369101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional