Healthcare Provider Details

I. General information

NPI: 1689351330
Provider Name (Legal Business Name): BROOKE ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8229 BOONE BLVD STE 660
VIENNA VA
22182-2657
US

IV. Provider business mailing address

3090 S GLEBE RD
ARLINGTON VA
22206-2770
US

V. Phone/Fax

Practice location:
  • Phone: 703-821-1363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202010904
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: