Provider Demographics
NPI:1760690234
Name:BROOKS, LEONIE JEANNENE (PHD)
Entity type:Individual
Prefix:DR
First Name:LEONIE
Middle Name:JEANNENE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CROSSROADS DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5419
Mailing Address - Country:US
Mailing Address - Phone:410-303-6722
Mailing Address - Fax:410-363-9262
Practice Address - Street 1:20 CROSSROADS DR
Practice Address - Street 2:SUITE 104
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5419
Practice Address - Country:US
Practice Address - Phone:410-303-6722
Practice Address - Fax:410-363-9262
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03292103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDGP72LJOtherBLUE CROSS BLUE SHIELD
MDS2010001OtherBLUE CROSS BLUE SHIELD