Provider Demographics
NPI:1366578353
Name:BROOKS, SUSAN LYNN (MDIV)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 571097
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-1097
Mailing Address - Country:US
Mailing Address - Phone:336-716-0863
Mailing Address - Fax:336-716-0822
Practice Address - Street 1:403 SOUTH HAWTHORNE ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1097
Practice Address - Country:US
Practice Address - Phone:336-716-0863
Practice Address - Fax:336-716-0822
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2321101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC9480OtherMEDCOST
NC130X1OtherBCBS