Basic Information
Provider Information | |||||||||
NPI: | 1295085389 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROOKS | ||||||||
FirstName: | ANNALIE | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S., SLP-CF | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2451 AMBERLEIGH DR | ||||||||
Address2: |   | ||||||||
City: | PLAINFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 461684714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124868030 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1701 LIBRARY BLVD STE A | ||||||||
Address2: |   | ||||||||
City: | GREENWOOD | ||||||||
State: | IN | ||||||||
PostalCode: | 461421567 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178819923 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2012 | ||||||||
LastUpdateDate: | 09/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 46002387A | IN | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 2202006818 | VA | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.