Healthcare Provider Details

I. General information

NPI: 1609995919
Provider Name (Legal Business Name): BROOKE FRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 13TH ST
HUNTINGTON WV
25701-1653
US

IV. Provider business mailing address

PO BOX 672
WAYNE WV
25570-0672
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-7622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberWV0538
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: