Provider Demographics
NPI:1003383092
Name:OFTEDAL, BROOKE LEIGH (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:LEIGH
Last Name:OFTEDAL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 MOROCCO DR
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-5430
Mailing Address - Country:US
Mailing Address - Phone:406-671-1854
Mailing Address - Fax:
Practice Address - Street 1:1750 MOROCCO DR
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-5430
Practice Address - Country:US
Practice Address - Phone:406-671-1854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-27
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-7301235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist