Healthcare Provider Details

I. General information

NPI: 1326247214
Provider Name (Legal Business Name): BROOKE R MOSER ST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 LUTE RD
PORTAGE IN
46368-5008
US

IV. Provider business mailing address

809 VALE PARK RD APT 2C
VALPARAISO IN
46383-2649
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-6858
  • Fax: 219-763-4858
Mailing address:
  • Phone: 435-512-5994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22004423A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: