Provider Demographics
NPI:1730228057
Name:WALLACE, BROOKE MARY (LCSW, BCD)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:MARY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:MRS
Other - First Name:BROOKE
Other - Middle Name:MARY
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, BCD
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:JBSA FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-508-9058
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-508-9058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX516431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical