Provider Demographics
NPI:1073250551
Name:BROCKETTE, ALLISON CLAIRE
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:CLAIRE
Last Name:BROCKETTE
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 1:9615 DOVE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-6209
Mailing Address - Country:US
Mailing Address - Phone:214-206-6691
Mailing Address - Fax:
Practice Address - Street 1:9615 DOVE MEADOW DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-6209
Practice Address - Country:US
Practice Address - Phone:214-206-6691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116833235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659249401Medicaid