Provider Demographics
NPI:1184952970
Name:BROOKS, BEATA MARIANNA (CCC/SLP)
Entity type:Individual
Prefix:MS
First Name:BEATA
Middle Name:MARIANNA
Last Name:BROOKS
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:MS
Other - First Name:BEATA
Other - Middle Name:MARIANNA
Other - Last Name:WAZNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC/SLP
Mailing Address - Street 1:2205 HURLEY AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1829
Mailing Address - Country:US
Mailing Address - Phone:817-888-0442
Mailing Address - Fax:817-924-7658
Practice Address - Street 1:2205 HURLEY AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1829
Practice Address - Country:US
Practice Address - Phone:817-888-0422
Practice Address - Fax:817-924-7658
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-07
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104475235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX805T852OtherBLUE CROSS BLUE SHIELD
TX208626601Medicaid