Provider Demographics
NPI:1396275137
Name:TRUEBLOOD, BROOKE J (SLP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:J
Last Name:TRUEBLOOD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 HIGHWAY AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1631
Mailing Address - Country:US
Mailing Address - Phone:219-513-8311
Mailing Address - Fax:
Practice Address - Street 1:2906 HIGHWAY AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1631
Practice Address - Country:US
Practice Address - Phone:219-513-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN29001725A2355S0801X
IN22007749A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN22007749AMedicaid