=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235818121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAKENNA JO BRESTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2023
-----------------------------------------------------
Last Update Date | 07/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5412 83RD ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-3438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-317-8412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 N 12TH ST
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68002-3096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-317-8412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------