Provider Demographics
NPI:1306639489
Name:LONG, BROOKE LEONE (LMSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LEONE
Last Name:LONG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 NEZ PERCE AVE
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2268
Mailing Address - Country:US
Mailing Address - Phone:208-360-2626
Mailing Address - Fax:
Practice Address - Street 1:229 NEZ PERCE AVE
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2268
Practice Address - Country:US
Practice Address - Phone:208-360-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3171763104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker