Provider Demographics
NPI:1811926207
Name:BROCKMAN, HEATHER JEAN (CCC, SLP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:JEAN
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:CCC, SLP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:JEAN
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC/SLP
Mailing Address - Street 1:400 EAST THIRD STREET
Mailing Address - Street 2:SSB-5
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-3146
Mailing Address - Fax:
Practice Address - Street 1:1600 MILLER TRUNK HWY BLDG C
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-5640
Practice Address - Country:US
Practice Address - Phone:218-786-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7675235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4600814OtherMEDICA
WI42568100Medicaid