Provider Demographics
NPI:1124883517
Name:BROOKS, BYRON DESALVIO (PHD)
Entity type:Individual
Prefix:DR
First Name:BYRON
Middle Name:DESALVIO
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 E 56TH ST APT 617
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1974
Mailing Address - Country:US
Mailing Address - Phone:864-561-4723
Mailing Address - Fax:
Practice Address - Street 1:1642 E 56TH ST APT 617
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1974
Practice Address - Country:US
Practice Address - Phone:864-561-4723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical