Basic Information
| Provider Information | |||||||||
| NPI: | 1083811608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | S.I. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FARRY | ||||||||
| OtherFirstName: | BROOKE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | S.I. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 602 VONDERBURG DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 VONDERBURG DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA11282 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 2355S0801X | SI1381 | FL | N | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 235Z00000X | SZ5188 | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 002805400 | 05 | FL | MEDICAID | 001476500 | 05 | FL | MEDICAID |