Basic Information
| Provider Information | |||||||||
| NPI: | 1578990776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | LCSW, LCADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6110 SHALLOWFORD RD STE B | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234991031 | ||||||||
| FaxNumber: | 2708860392 | ||||||||
| Practice Location | |||||||||
| Address1: | 6110 SHALLOWFORD RD STE B | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4294991031 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
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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 | 1123 | KY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 3993 | KY | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 3993 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 7100333360 | 05 | KY | MEDICAID |