Basic Information
| Provider Information | |||||||||
| NPI: | 1255983763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LASSIE-ROSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 OAK GROVE RD | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385837126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313190814 | ||||||||
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| Practice Location | |||||||||
| Address1: | 264 JUDAH DR | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385838710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313190814 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2019 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 5026 | TN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.