Provider Demographics
NPI:1285177691
Name:BROKAW, MATTIE
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:BROKAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 E VIA PALOMITA APT 30204
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-3363
Mailing Address - Country:US
Mailing Address - Phone:317-695-2610
Mailing Address - Fax:
Practice Address - Street 1:1010 E 10TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5813
Practice Address - Country:US
Practice Address - Phone:317-695-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP10066235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist