Provider Demographics
NPI:1841423258
Name:BRASEL, LORI DIANE (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:DIANE
Last Name:BRASEL
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 1:117 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2643
Mailing Address - Country:US
Mailing Address - Phone:918-237-6067
Mailing Address - Fax:
Practice Address - Street 1:1202 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3866
Practice Address - Country:US
Practice Address - Phone:307-856-4337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2668235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09135452OtherAMERICAN SPEECH-LANGUAGE AND HEARING ASSOCIATION
OK2668OtherSTATE OF OKLAHOMA BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY
WYSP-891OtherSTATE LICENSE