Healthcare Provider Details

I. General information

NPI: 1619801412
Provider Name (Legal Business Name): BROOKE M.B. KINNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SOUTH ST
WAUNAKEE WI
53597-1419
US

IV. Provider business mailing address

905 BETHEL CIR
WAUNAKEE WI
53597-9589
US

V. Phone/Fax

Practice location:
  • Phone: 608-849-2000
  • Fax:
Mailing address:
  • Phone: 608-393-5491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number631755
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: