Provider Demographics
NPI:1124861471
Name:STANLEY, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:STANLEY
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 1:296 BEAUVOIR RD STE 100-1311
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4051
Mailing Address - Country:US
Mailing Address - Phone:228-707-4417
Mailing Address - Fax:228-678-7877
Practice Address - Street 1:296 BEAUVOIR RD STE 100-1311
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4051
Practice Address - Country:US
Practice Address - Phone:228-707-4417
Practice Address - Fax:228-678-7877
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-24-351758106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician