Provider Demographics
NPI:1912419607
Name:BROOKSHIRE, CAROLE LEE (MFT 115869)
Entity type:Individual
Prefix:
First Name:CAROLE
Middle Name:LEE
Last Name:BROOKSHIRE
Suffix:
Gender:F
Credentials:MFT 115869
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11564 POEMA PL UNIT 101
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-1153
Mailing Address - Country:US
Mailing Address - Phone:818-613-8417
Mailing Address - Fax:
Practice Address - Street 1:660 E LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1873
Practice Address - Country:US
Practice Address - Phone:818-206-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9298101YA0400X
CA115869101YA0400X, 101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA99597OtherMFTI