Provider Demographics
NPI:1982723359
Name:BUTLER, BROOKE LYNN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LYNN
Last Name:BUTLER
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 1:2824 BEAVERTAIL LN
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-7247
Mailing Address - Country:US
Mailing Address - Phone:602-380-3161
Mailing Address - Fax:
Practice Address - Street 1:2824 BEAVERTAIL LN
Practice Address - Street 2:
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-7247
Practice Address - Country:US
Practice Address - Phone:602-380-3161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4519235Z00000X
AZTSLP4519235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109316Medicaid
AZTSLP4519OtherARIZONA LICESNSE NUMBER