Provider Demographics
NPI:1609402965
Name:LOLLEY, BROOKE (SLP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:LOLLEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HOLLYWOOD BLVD SW STE 7
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4893
Mailing Address - Country:US
Mailing Address - Phone:850-226-7411
Mailing Address - Fax:850-226-7496
Practice Address - Street 1:24 HOLLYWOOD BLVD SW STE 7
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4893
Practice Address - Country:US
Practice Address - Phone:850-226-7411
Practice Address - Fax:850-226-7496
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8376235Z00000X
FL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA8376OtherSTATE LICENSE