Provider Demographics
NPI:1437960416
Name:DIEMER, BROOKLYN CAMILLE
Entity type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:CAMILLE
Last Name:DIEMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 CHESTNUT CT
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-2117
Mailing Address - Country:US
Mailing Address - Phone:872-222-3735
Mailing Address - Fax:
Practice Address - Street 1:390 E CONGRESS PKWY STE M
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6207
Practice Address - Country:US
Practice Address - Phone:866-429-7543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IARBT-24-376010106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician