Provider Demographics
NPI:1306248794
Name:BRAINWORKS PEDIATRIC GROUP LLC
Entity type:Organization
Organization Name:BRAINWORKS PEDIATRIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKELMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-240-8096
Mailing Address - Street 1:2120 BRYAN VALLEY COMMERCIAL DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3495
Mailing Address - Country:US
Mailing Address - Phone:636-240-8096
Mailing Address - Fax:636-272-4484
Practice Address - Street 1:2120 BRYAN VALLEY COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3495
Practice Address - Country:US
Practice Address - Phone:636-240-8096
Practice Address - Fax:636-272-4484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty