Provider Demographics
NPI:1134732001
Name:NGUYEN, BROOKE MARIE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:MARIE
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:MS 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:PO BOX 416501
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-7594
Mailing Address - Country:US
Mailing Address - Phone:309-948-6469
Mailing Address - Fax:
Practice Address - Street 1:2103 N VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0908
Practice Address - Country:US
Practice Address - Phone:309-948-6469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.005723235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL242.005723Medicaid