Healthcare Provider Details

I. General information

NPI: 1093399370
Provider Name (Legal Business Name): TRISTAN BROOKE MCLEAN SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 05/12/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 KIMBERLY LN
WILLIAMSTOWN KY
41097-9458
US

IV. Provider business mailing address

323 ASTORIA LN
MONTICELLO KY
42633-7399
US

V. Phone/Fax

Practice location:
  • Phone: 859-824-7803
  • Fax:
Mailing address:
  • Phone: 606-307-3027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number270379
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: