Basic Information
| Provider Information | |||||||||
| NPI: | 1003119603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROOKS | ||||||||
| OtherFirstName: | ERICA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1321 FIRST ST W | ||||||||
| Address2: | |||||||||
| City: | AHOSKIE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279108842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522098932 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1321 FIRST ST W | ||||||||
| Address2: | |||||||||
| City: | AHOSKIE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279108842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522098932 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2010 | ||||||||
| LastUpdateDate: | 12/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 2526 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 138A2 | 01 | NC | BCBSNC | OTHER | 6107194 | 05 | NC | MEDICAID |