Healthcare Provider Details

I. General information

NPI: 1790691889
Provider Name (Legal Business Name): BROOKE CHILDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TIGER DR
WAVERLY OH
45690-8704
US

IV. Provider business mailing address

120 AMERICAN BLVD
PIKETON OH
45661-7500
US

V. Phone/Fax

Practice location:
  • Phone: 740-947-4770
  • Fax:
Mailing address:
  • Phone: 740-289-4171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberCOND.20263634-SP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: