Provider Demographics
NPI:1790308385
Name:OLTSIK, BROOKE ASHLEY
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ASHLEY
Last Name:OLTSIK
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 1:25300 N 22ND LN APT 1110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8806
Mailing Address - Country:US
Mailing Address - Phone:309-212-0574
Mailing Address - Fax:
Practice Address - Street 1:21045 N 9TH PL STE 204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-5635
Practice Address - Country:US
Practice Address - Phone:480-599-4734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-001912103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician