Healthcare Provider Details

I. General information

NPI: 1194218545
Provider Name (Legal Business Name): BROOKE ELIZABETH MAHONEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 LONG BEACH BLVD STE 700
LONG BEACH CA
90807-2000
US

IV. Provider business mailing address

110 TRUEHEDGE TRCE
ROSWELL GA
30076-2907
US

V. Phone/Fax

Practice location:
  • Phone: 818-894-2273
  • Fax: 818-357-2505
Mailing address:
  • Phone: 808-383-4782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP.15361
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number33651
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberPCET002711
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP010528
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: