Provider Demographics
NPI:1326247214
Name:MOSER, BROOKE R (ST)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:R
Last Name:MOSER
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 VALE PARK RD
Mailing Address - Street 2:APT 2C
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2649
Mailing Address - Country:US
Mailing Address - Phone:435-512-5994
Mailing Address - Fax:
Practice Address - Street 1:6040 LUTE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5008
Practice Address - Country:US
Practice Address - Phone:219-763-6858
Practice Address - Fax:219-763-4858
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004423A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN22004423AOtherST