Provider Demographics
NPI:1407393648
Name:HERBECK, BRETT
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:HERBECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:IL
Mailing Address - Zip Code:61252-1307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 28TH AVE N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-1955
Practice Address - Country:US
Practice Address - Phone:563-243-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001671235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist