Provider Demographics
NPI:1497960991
Name:BLAIR, BROOKE Q LUNDAHL (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE Q
Middle Name:LUNDAHL
Last Name:BLAIR
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 1:704 JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-1312
Mailing Address - Country:US
Mailing Address - Phone:718-916-9326
Mailing Address - Fax:
Practice Address - Street 1:622 WEST 168TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3784
Practice Address - Country:US
Practice Address - Phone:212-305-4958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016259-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist