Basic Information
| Provider Information | |||||||||
| NPI: | 1841210408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | BRUCE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LADC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 550 S PEORIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741203820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185881900 | ||||||||
| FaxNumber: | 9185826405 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 S PEORIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741203820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185881900 | ||||||||
| FaxNumber: | 9185826405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 91 | OK | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 2582 | OK | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1201485 | 05 | OK | MEDICAID |