Provider Demographics
NPI:1356195598
Name:BETLAF, BROOKE NICOLE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:BETLAF
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 1:3455 WILKENS AVE LOWR LEVEL20
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5213
Mailing Address - Country:US
Mailing Address - Phone:410-646-6970
Mailing Address - Fax:410-644-5609
Practice Address - Street 1:3455 WILKENS AVE LOWR LEVEL20
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5213
Practice Address - Country:US
Practice Address - Phone:410-646-6970
Practice Address - Fax:410-644-5609
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT3463101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)