Provider Demographics
NPI:1245613314
Name:BROOKS, PHYLLIS DENISE
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:DENISE
Last Name:BROOKS
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 1:1017 MURANDY LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-8052
Mailing Address - Country:US
Mailing Address - Phone:704-451-5633
Mailing Address - Fax:844-294-3070
Practice Address - Street 1:1017 MURANDY LN
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-8052
Practice Address - Country:US
Practice Address - Phone:704-451-5633
Practice Address - Fax:844-294-3070
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11178235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist