Provider Demographics
NPI:1679016869
Name:FAHRENBROOK, TINA ROMERO (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:ROMERO
Last Name:FAHRENBROOK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MISS
Other - First Name:TINA
Other - Middle Name:KATHERINE
Other - Last Name:ROMERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, SLP
Mailing Address - Street 1:1600 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:GERING
Mailing Address - State:NE
Mailing Address - Zip Code:69341-1914
Mailing Address - Country:US
Mailing Address - Phone:308-436-5555
Mailing Address - Fax:
Practice Address - Street 1:1900 FLATEN AVE
Practice Address - Street 2:
Practice Address - City:GERING
Practice Address - State:NE
Practice Address - Zip Code:69341-1850
Practice Address - Country:US
Practice Address - Phone:308-436-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2016003984235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE23520000XMedicaid