Provider Demographics
NPI:1841214509
Name:FAHRENBROOK, KURT (AUD, CCC-A)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:FAHRENBROOK
Suffix:
Gender:M
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:308-635-3155
Mailing Address - Fax:
Practice Address - Street 1:2 W 42ND ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4669
Practice Address - Country:US
Practice Address - Phone:308-635-3155
Practice Address - Fax:308-635-2966
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE123231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE123Medicaid
NE640002691OtherPALMENTO GBA RR MEDICARE
NE268822Medicare PIN