Provider Demographics
NPI:1710736301
Name:BROOKS, SHANTAE
Entity type:Individual
Prefix:
First Name:SHANTAE
Middle Name:
Last Name:BROOKS
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 1:870 SHERBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1300
Mailing Address - Country:US
Mailing Address - Phone:313-614-8940
Mailing Address - Fax:
Practice Address - Street 1:31300 NORTHWESTERN HWY STE A
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5407
Practice Address - Country:US
Practice Address - Phone:248-254-3318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704298442363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health