Provider Demographics
NPI:1437195971
Name:BROOKS, BEVERLY JO
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JO
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:JO
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:PILOT MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:27041-0483
Mailing Address - Country:US
Mailing Address - Phone:336-368-9567
Mailing Address - Fax:
Practice Address - Street 1:351 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3850
Practice Address - Country:US
Practice Address - Phone:336-783-6919
Practice Address - Fax:336-783-6923
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0021221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003318Medicaid