Individual
MISS BROOKE MARY WAY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
6634 OLD STATESVILLE RD, CHARLOTTE, NC 28269-6768
(704) 313-5874
Mailing address
6634 OLD STATESVILLE RD, CHARLOTTE, NC 28269-6768
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
—
—
106S00000X
Behavior Technician
—
—
3747P1801X
Personal Care Attendant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
MMJ892451483
BLUE CROSS BLUE SHIELD
—
Enumeration date
08/10/2018
Last updated
01/09/2025
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