Provider Demographics
NPI:1629181672
Name:BRACKEN, AMY JO (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:BRACKEN
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 1:4923 PHOENIX DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6925
Mailing Address - Country:US
Mailing Address - Phone:307-778-7554
Mailing Address - Fax:307-778-7369
Practice Address - Street 1:2360 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-778-7554
Practice Address - Fax:307-778-7369
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-371235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist