Provider Demographics
NPI:1366988628
Name:MEADATH, BROCK IRVIN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:IRVIN
Last Name:MEADATH
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1687
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24543-1687
Mailing Address - Country:US
Mailing Address - Phone:434-793-8255
Mailing Address - Fax:434-793-6017
Practice Address - Street 1:742 WILSON ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541
Practice Address - Country:US
Practice Address - Phone:434-793-8255
Practice Address - Fax:434-793-6017
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL014295235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist