Provider Demographics
NPI:1154487908
Name:WALDRON, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WALDRON
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 1:1021 W 68TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64113-1922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 W 68TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64113-1922
Practice Address - Country:US
Practice Address - Phone:816-363-2052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006000676235Z00000X
KS2615235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO36592011OtherBCBS