Provider Demographics
NPI:1427723337
Name:GOLDIZEN, BROOKE ANN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANN
Last Name:GOLDIZEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ANN
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1320 RIVERBEND DR APT 106
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-6007
Mailing Address - Country:US
Mailing Address - Phone:304-902-0125
Mailing Address - Fax:
Practice Address - Street 1:340 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-3526
Practice Address - Country:US
Practice Address - Phone:276-386-6118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202010070235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist