Provider Demographics
NPI:1407300122
Name:MARTIN, BROOKE F (MS, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:BROOKE
Middle Name:F
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:E
Other - Last Name:FORSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 NE 47TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2212
Practice Address - Country:US
Practice Address - Phone:503-215-2278
Practice Address - Fax:503-215-2478
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15572235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500719144Medicaid