Provider Demographics
NPI:1104644731
Name:SLATTERY, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:SLATTERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SHEPPLER ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-5513
Mailing Address - Country:US
Mailing Address - Phone:585-730-2784
Mailing Address - Fax:
Practice Address - Street 1:625 PANORAMA TRL STE 210
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2408
Practice Address - Country:US
Practice Address - Phone:585-730-2784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114216104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker