Provider Demographics
NPI:1194011460
Name:BROCKMAN, MARY DENISE (MA, CCC(SLP))
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:DENISE
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:MA, CCC(SLP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 WINBERIE CT
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-7691
Mailing Address - Country:US
Mailing Address - Phone:248-760-2448
Mailing Address - Fax:832-437-4862
Practice Address - Street 1:2214 WINBERIE CT
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7691
Practice Address - Country:US
Practice Address - Phone:248-760-2448
Practice Address - Fax:832-437-4862
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist