Provider Demographics
NPI:1689414054
Name:VAN BROCKLIN, TAWNYA (SLP MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TAWNYA
Middle Name:
Last Name:VAN BROCKLIN
Suffix:
Gender:F
Credentials:SLP 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 1:2275 MORNINGLORY DR
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434-3502
Mailing Address - Country:US
Mailing Address - Phone:775-338-0438
Mailing Address - Fax:
Practice Address - Street 1:2275 MORNINGLORY DR
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-3502
Practice Address - Country:US
Practice Address - Phone:775-338-0438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist