Provider Demographics
NPI:1407407257
Name:FAIRCLOTH, BROOKE ELIZABETH (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
Last Name:FAIRCLOTH
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 1:3015 S YSABELLA AVE APT F
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-8160
Mailing Address - Country:US
Mailing Address - Phone:813-244-7616
Mailing Address - Fax:
Practice Address - Street 1:8254 118TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-5027
Practice Address - Country:US
Practice Address - Phone:727-541-5304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9314235Z00000X
FLSA18082235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist