Provider Demographics
NPI:1639847254
Name:BRAZEAL, ELISABETH
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:BRAZEAL
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 1:300 TIMBER RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-7169
Mailing Address - Country:US
Mailing Address - Phone:870-917-8973
Mailing Address - Fax:
Practice Address - Street 1:23247 I 30 UNIT 7
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-2571
Practice Address - Country:US
Practice Address - Phone:501-313-0592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2016122355S0801X
AR235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant