Provider Demographics
NPI:1609620178
Name:BRENNECKE, GRACE ROSE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ROSE
Last Name:BRENNECKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 LAKE DR STE 270
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-2504
Mailing Address - Country:US
Mailing Address - Phone:515-225-6212
Mailing Address - Fax:
Practice Address - Street 1:6800 LAKE DR STE 270
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-2504
Practice Address - Country:US
Practice Address - Phone:515-225-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA124018235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist