Provider Demographics
NPI:1659786747
Name:IBANEZ, BROOKE WILY (LCSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:WILY
Last Name:IBANEZ
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:IBANEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:552 N 1540 W
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-2076
Mailing Address - Country:US
Mailing Address - Phone:801-919-4854
Mailing Address - Fax:385-900-1637
Practice Address - Street 1:2578 W 600 N STE 102
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-1260
Practice Address - Country:US
Practice Address - Phone:385-220-0770
Practice Address - Fax:385-900-1637
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT526223135021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical