Basic Information
| Provider Information | |||||||||
| NPI: | 1235681339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4138 ROUTE 52 | ||||||||
| Address2: | |||||||||
| City: | HOLMES | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125315109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455194111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15 FORTUNE ROAD | ||||||||
| Address2: | |||||||||
| City: | WEST MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456924454 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2016 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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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 | 101YP2500X | 097180 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.