Provider Demographics
NPI:1972116846
Name:LUNSFORD, BROOKE B (LCSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:B
Last Name:LUNSFORD
Suffix:
Gender:F
Credentials:LCSW
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 131
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0131
Mailing Address - Country:US
Mailing Address - Phone:208-210-6445
Mailing Address - Fax:208-601-6162
Practice Address - Street 1:13403 N GOVERNMENT WAY STE 118
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8906
Practice Address - Country:US
Practice Address - Phone:208-210-6445
Practice Address - Fax:208-601-6162
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099297401041C0700X
IDLCSW-433441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY4035142OtherDRIVERS LICENSE