Provider Demographics
NPI:1518017839
Name:BREKKE, TOM W (BS, MS)
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:W
Last Name:BREKKE
Suffix:
Gender:M
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-3718
Mailing Address - Country:US
Mailing Address - Phone:417-523-0026
Mailing Address - Fax:
Practice Address - Street 1:1461 N DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-1779
Practice Address - Country:US
Practice Address - Phone:417-523-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist