Provider Demographics
NPI:1689298101
Name:PRUIETT, BROOKE MARIE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:MARIE
Last Name:PRUIETT
Suffix:
Gender:F
Credentials: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:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-0608
Mailing Address - Country:US
Mailing Address - Phone:573-472-0397
Mailing Address - Fax:
Practice Address - Street 1:300 FLOYD DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-3960
Practice Address - Country:US
Practice Address - Phone:573-472-0397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020014582235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist