Provider Demographics
NPI:1568712073
Name:BROOKE, RENEE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:BROOKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 JACOB CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-8448
Mailing Address - Country:US
Mailing Address - Phone:503-707-6965
Mailing Address - Fax:
Practice Address - Street 1:21 JACOB CT
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-8448
Practice Address - Country:US
Practice Address - Phone:503-707-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA455277D235Z00000X
OR10366890235Z00000X
FLSA 12462235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist