Provider Demographics
NPI:1780776856
Name:BROOKS, RONALD E JR (EDM)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:E
Last Name:BROOKS
Suffix:JR
Gender:M
Credentials:EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-3715
Mailing Address - Country:US
Mailing Address - Phone:215-340-0143
Mailing Address - Fax:
Practice Address - Street 1:354 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-3715
Practice Address - Country:US
Practice Address - Phone:215-340-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004407-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101667583 0001Medicaid