Provider Demographics
NPI:1396256343
Name:BROCKL, AMBER MARIE (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:MARIE
Last Name:BROCKL
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 1:4102 S MERIDIAN
Mailing Address - Street 2:STE E5
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5962
Mailing Address - Country:US
Mailing Address - Phone:253-282-2326
Mailing Address - Fax:844-517-6511
Practice Address - Street 1:1600 SLEATER KINNEY RD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2500
Practice Address - Country:US
Practice Address - Phone:360-438-7881
Practice Address - Fax:360-456-1719
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003256235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist