Provider Demographics
NPI:1730534181
Name:BROOKS, KATHERINE WINGATE (BS/MS/MDIV)
Entity type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:WINGATE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:BS/MS/MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 CITIZEN CIR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-4803
Mailing Address - Country:US
Mailing Address - Phone:757-816-4785
Mailing Address - Fax:757-493-3635
Practice Address - Street 1:305 CITIZEN CIR
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23325-4803
Practice Address - Country:US
Practice Address - Phone:757-816-4785
Practice Address - Fax:757-493-3635
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0103323975Medicaid