Provider Demographics
NPI:1316317472
Name:BROOKS, CHARLIE II
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:BROOKS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6692 VISTA OAKS CT
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7480
Mailing Address - Country:US
Mailing Address - Phone:318-332-6033
Mailing Address - Fax:
Practice Address - Street 1:1632 THOMAS H DELPIT DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-6628
Practice Address - Country:US
Practice Address - Phone:225-778-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009713647101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health