Provider Demographics
NPI:1003395898
Name:ROBERTS, BRENNA MERRY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:MERRY
Last Name:ROBERTS
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 1:49 BALSAM ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-1417
Mailing Address - Country:US
Mailing Address - Phone:315-532-9676
Mailing Address - Fax:
Practice Address - Street 1:1000 ELMWOOD AVE STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3093
Practice Address - Country:US
Practice Address - Phone:315-532-9676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027954235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty