Healthcare Provider Details

I. General information

NPI: 1265040695
Provider Name (Legal Business Name): BROOKE CHRISTINE EDGREN MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 1ST AVE
ELWOOD NE
68937-5208
US

IV. Provider business mailing address

PO BOX 107
ELWOOD NE
68937-0107
US

V. Phone/Fax

Practice location:
  • Phone: 308-785-2491
  • Fax:
Mailing address:
  • Phone: 308-785-2491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2429
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: