Healthcare Provider Details

I. General information

NPI: 1013539378
Provider Name (Legal Business Name): BROOKE KITTLESON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2020
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 SHERBURN CT
ORLANDO FL
32828-9017
US

IV. Provider business mailing address

2965 GRANDEVILLE CIR APT 307
OVIEDO FL
32765-6080
US

V. Phone/Fax

Practice location:
  • Phone: 407-810-2773
  • Fax: 407-867-6203
Mailing address:
  • Phone: 407-592-6906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ9350
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: