Provider Demographics
NPI:1669255212
Name:LONG, BROOKE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3186 SUNFLOWER PL
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-3528
Mailing Address - Country:US
Mailing Address - Phone:740-851-7538
Mailing Address - Fax:
Practice Address - Street 1:510 E NORTH BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4114
Practice Address - Country:US
Practice Address - Phone:614-263-5365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.15446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist