MEDICARE: HEATHER JEAN BROCKMAN CCC, SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7675	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4600814	OTHER		MEDICA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811926207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER JEAN BROCKMAN CCC, SLP

Provider Business Mailing Address
First Line	:	400 EAST THIRD STREET
Second Line	:	SSB-5
City	:	DULUTH
State	:	MN
Zip	:	55805-1951
Country	:	US
Telephone Number	:	218-786-3146
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 MILLER TRUNK HWY BLDG C
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55811-5640
Country	:	US
Telephone Number	:	218-786-5360
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	12/21/2020

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