Basic Information
| Provider Information | |||||||||
| NPI: | 1609150275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | MYRA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MSW,LPC,LCSW,SAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22040 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498014631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067769040 | ||||||||
| FaxNumber: | 9067745950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2011 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401009846 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 15626-132 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 3808-125 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | 8130-123 | WI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 68010933800 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.