Provider Demographics
NPI:1679091672
Name:ROSENTHAL, BROOKE NICOLE (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:NICOLE
Last Name:ROSENTHAL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8293 MINE AVE
Mailing Address - Street 2:
Mailing Address - City:MORRISONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62546-6010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 ROCKET DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IL
Practice Address - Zip Code:62563-9282
Practice Address - Country:US
Practice Address - Phone:217-498-9778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008327235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty