Provider Demographics
NPI:1013539378
Name:KITTLESON, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:KITTLESON
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 1:2965 GRANDEVILLE CIR APT 307
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6080
Mailing Address - Country:US
Mailing Address - Phone:407-592-6906
Mailing Address - Fax:
Practice Address - Street 1:606 SHERBURN CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9017
Practice Address - Country:US
Practice Address - Phone:407-810-2773
Practice Address - Fax:407-867-6203
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-09
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty