Basic Information
| Provider Information | |||||||||
| NPI: | 1356778435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5427 WOODROW LN | ||||||||
| Address2: | |||||||||
| City: | HAHIRA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316322551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2297941748 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 907 18TH ST E | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2013 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 004972 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.