Provider Demographics
NPI:1316743016
Name:VAN BROCKLIN, BRANDE GWEN (MA CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:BRANDE
Middle Name:GWEN
Last Name:VAN BROCKLIN
Suffix:
Gender:
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4718
Mailing Address - Country:US
Mailing Address - Phone:619-756-8070
Mailing Address - Fax:
Practice Address - Street 1:633 MONROE AVE
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4718
Practice Address - Country:US
Practice Address - Phone:619-756-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-22
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33487235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist