Healthcare Provider Details

I. General information

NPI: 1144656042
Provider Name (Legal Business Name): BROOKS SPEECH LANGUAGE THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 TAPP RD
VAN BUREN AR
72956-6844
US

IV. Provider business mailing address

1117 TAPP RD
VAN BUREN AR
72956-6844
US

V. Phone/Fax

Practice location:
  • Phone: 321-501-0282
  • Fax:
Mailing address:
  • Phone: 321-501-0282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP 487
License Number StateAR

VIII. Authorized Official

Name: SYDNEY BROOKS MASON
Title or Position: SPEECH/LANGUAGE PATHOLOGIST
Credential: CCC-SLP
Phone: 321-501-0282