Provider Demographics
NPI:1235017328
Name:EWBANK, BROOKLYN (LMSW)
Entity type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:
Last Name:EWBANK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:BROOKLYN
Other - Middle Name:NICOLE
Other - Last Name:BUSHNELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:421 N GARY AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-2923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 S ASH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MO
Practice Address - Zip Code:65622-8674
Practice Address - Country:US
Practice Address - Phone:417-345-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024010969104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker