Provider Demographics
NPI:1235965252
Name:BERRY, BROOKE WILSON
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:WILSON
Last Name:BERRY
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 1:101 S ALLUMBAUGH WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5658
Mailing Address - Country:US
Mailing Address - Phone:208-323-8888
Mailing Address - Fax:
Practice Address - Street 1:101 S ALLUMBAUGH WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-5658
Practice Address - Country:US
Practice Address - Phone:208-323-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4961960104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker