Basic Information
Provider Information | |||||||||
NPI: | 1275772881 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GARDNER | ||||||||
FirstName: | BROOKE | ||||||||
MiddleName: | SELIG | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S. CF-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SELIG | ||||||||
OtherFirstName: | BROOKE | ||||||||
OtherMiddleName: | ELLEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 251418 | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722251418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013641100 | ||||||||
FaxNumber: | 5015265148 | ||||||||
Practice Location | |||||||||
Address1: | 1301 WOLFE ST RM 332 | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722025320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5015268008 | ||||||||
FaxNumber: | 5015268047 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2009 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP#P8135 | AR | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | SP2700 | AR | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 174996721 | 05 | AR |   | MEDICAID |