Provider Demographics
NPI:1861960262
Name:CUNDIFF, BROOKE SHANNON
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:SHANNON
Last Name:CUNDIFF
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 1:1045 MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1800
Mailing Address - Country:US
Mailing Address - Phone:276-340-6124
Mailing Address - Fax:
Practice Address - Street 1:404 RIVES RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-4327
Practice Address - Country:US
Practice Address - Phone:276-340-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty