Basic Information
| Provider Information | |||||||||
| NPI: | 1235761578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | ELICIA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MA, LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7700 MCGLADE SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | DRESDEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 438219744 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2845 BELL ST | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404549766 | ||||||||
| FaxNumber: | 7405886452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2020 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1901206-TRNE | OH | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | S.2106293 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0389660 | 05 | OH | MEDICAID |