Provider Demographics
NPI:1528430642
Name:EVANS, BROOKE (LSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5617
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-5617
Mailing Address - Country:US
Mailing Address - Phone:970-389-5524
Mailing Address - Fax:
Practice Address - Street 1:101 W. MAIN ST.
Practice Address - Street 2:SUITE A
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-0000
Practice Address - Country:US
Practice Address - Phone:970-389-5524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical