Provider Demographics
NPI:1235682337
Name:EDSALL, BROOKE N (SLP)
Entity Type:Individual
Prefix:MISS
First Name:BROOKE
Middle Name:N
Last Name:EDSALL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2258 N LAKEWAY CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1082
Mailing Address - Country:US
Mailing Address - Phone:316-945-7117
Mailing Address - Fax:316-945-7447
Practice Address - Street 1:2258 N LAKEWAY CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1082
Practice Address - Country:US
Practice Address - Phone:316-945-7117
Practice Address - Fax:316-945-7447
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3909235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS480793004Medicaid