Provider Demographics
NPI:1568684611
Name:BROOKS, MILLIE R (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MILLIE
Middle Name:R
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 S. ROOS. RD. 2.5
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130
Mailing Address - Country:US
Mailing Address - Phone:505-693-4950
Mailing Address - Fax:
Practice Address - Street 1:1744 S. ROOS. RD. 2.5
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:505-693-4950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3383235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist