Provider Demographics
NPI:1225642325
Name:VAN REGENMORTER, BROOKE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:VAN REGENMORTER
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 1:11445 E VIA LINDA STE 2235
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-2655
Mailing Address - Country:US
Mailing Address - Phone:602-403-5220
Mailing Address - Fax:
Practice Address - Street 1:11445 E VIA LINDA
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-2655
Practice Address - Country:US
Practice Address - Phone:602-403-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP12433235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty