Provider Demographics
NPI:1538329206
Name:MCMAHAN, BROOKE M (AUD, CNIM)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:M
Last Name:MCMAHAN
Suffix:
Gender:F
Credentials:AUD, CNIM
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:M
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:15405 DAYBRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-9627
Mailing Address - Country:US
Mailing Address - Phone:405-249-1379
Mailing Address - Fax:
Practice Address - Street 1:15405 DAYBRIGHT DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-9627
Practice Address - Country:US
Practice Address - Phone:405-249-1379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK359231H00000X
246ZE0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200197630AMedicaid
OKOK401004Medicare UPIN