Provider Demographics
NPI:1689179319
Name:VAN BROCKLIN, ALISON
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:
Last Name:VAN BROCKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-3010
Mailing Address - Country:US
Mailing Address - Phone:404-509-7004
Mailing Address - Fax:
Practice Address - Street 1:154 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-7300
Practice Address - Country:US
Practice Address - Phone:662-563-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4364235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist