Basic Information
| Provider Information | |||||||||
| NPI: | 1437195971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLE | ||||||||
| OtherFirstName: | BEVERLY | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 483 | ||||||||
| Address2: | |||||||||
| City: | PILOT MOUNTAIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270410483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363689567 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 351 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270303850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367836919 | ||||||||
| FaxNumber: | 3367836923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C002122 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6003318 | 05 | NC | MEDICAID |