Basic Information
| Provider Information | |||||||||
| NPI: | 1629069620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | JUNE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | ED.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100039 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761850039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175468212 | ||||||||
| FaxNumber: | 8175468215 | ||||||||
| Practice Location | |||||||||
| Address1: | COLONIAL MANOR NURSING HOME | ||||||||
| Address2: | 2035 GRANBURY STREET | ||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176549134 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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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 | 103TC0700X | 2-1049 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 122328102 | 05 | TX | MEDICAID |