Basic Information
| Provider Information | |||||||||
| NPI: | 1558844845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RADT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15519 CRENSHAW BLVD | ||||||||
| Address2: | |||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902494525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106799126 | ||||||||
| FaxNumber: | 3106792920 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 W EL SEGUNDO BLVD | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902503317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237542816 | ||||||||
| FaxNumber: | 3237542828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2018 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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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 | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.