Provider Demographics
NPI:1154357721
Name:THE EDNA BROOKS FOUNDATION, INC.
Entity type:Organization
Organization Name:THE EDNA BROOKS FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:740-593-7125
Mailing Address - Street 1:PO BOX 1158
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1158
Mailing Address - Country:US
Mailing Address - Phone:740-593-7125
Mailing Address - Fax:740-594-7122
Practice Address - Street 1:142 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1746
Practice Address - Country:US
Practice Address - Phone:740-593-7125
Practice Address - Fax:740-594-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0003261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10167Medicaid