Provider Demographics
NPI:1407178155
Name:POLK, BROOKE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:POLK
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 1:1912 SPARROWRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-7714
Mailing Address - Country:US
Mailing Address - Phone:501-413-1393
Mailing Address - Fax:
Practice Address - Street 1:1912 SPARROWRIDGE CIR
Practice Address - Street 2:
Practice Address - City:HAUGHTON
Practice Address - State:LA
Practice Address - Zip Code:71037-7714
Practice Address - Country:US
Practice Address - Phone:501-413-1393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2164235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180245721Medicaid