Provider Demographics
NPI:1760631881
Name:HARTLEY, BROOKE SAREPTA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:SAREPTA
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:MA, 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:P.O. BOX 1191
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435
Mailing Address - Country:US
Mailing Address - Phone:307-754-2864
Mailing Address - Fax:307-754-9829
Practice Address - Street 1:808 NORTH STREET
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-5213
Practice Address - Country:US
Practice Address - Phone:307-527-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-468235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1770688871Medicaid