Provider Demographics
NPI:1205842739
Name:BROOK, JANET VALLESE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:VALLESE
Last Name:BROOK
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:PO BOX 58
Mailing Address - Street 2:1565 BOSQUECITO ROAD, SOCORRO, NM 87801
Mailing Address - City:LEMITAR
Mailing Address - State:NM
Mailing Address - Zip Code:87823-0058
Mailing Address - Country:US
Mailing Address - Phone:505-835-2118
Mailing Address - Fax:505-835-2118
Practice Address - Street 1:1565 BOSQUECITO ROAD
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801
Practice Address - Country:US
Practice Address - Phone:505-835-2118
Practice Address - Fax:505-835-2118
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM410235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000D1615Medicaid
NM410OtherSLP BOARD LICENSE
NM78902525Medicaid
NM01025724OtherASHA CERTIFIED
NM02083282006OtherCRS ID NUMBER