Basic Information
Provider Information | |||||||||
NPI: | 1225292170 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROOKS | ||||||||
FirstName: | AUDREY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUTTS | ||||||||
OtherFirstName: | AUDREY | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1300 E BRADFORD PKWY | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658044264 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4177615000 | ||||||||
FaxNumber: | 4177615011 | ||||||||
Practice Location | |||||||||
Address1: | 601 S US HIGHWAY 169 | ||||||||
Address2: |   | ||||||||
City: | SMITHVILLE | ||||||||
State: | MO | ||||||||
PostalCode: | 640899317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8165323700 | ||||||||
FaxNumber: | 8165327163 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2008 | ||||||||
LastUpdateDate: | 01/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 2016013807 | MO | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.