Provider Demographics
NPI:1932506078
Name:SOOTS, BRANDON (MA CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:SOOTS
Suffix:
Gender:M
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 1:5810 E COUNTY ROAD 100 N
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5810 E COUNTY ROAD 100 N
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8621
Practice Address - Country:US
Practice Address - Phone:765-730-2619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004963A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist