Provider Demographics
NPI:1760558373
Name:BROCKWELL, CHANTELLE (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CHANTELLE
Middle Name:
Last Name:BROCKWELL
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 HAYLOFT LN
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4180
Mailing Address - Country:US
Mailing Address - Phone:719-382-8571
Mailing Address - Fax:719-382-8571
Practice Address - Street 1:830 HAYLOFT LN
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-4180
Practice Address - Country:US
Practice Address - Phone:719-382-8571
Practice Address - Fax:719-382-8571
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12034960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist