Provider Demographics
NPI:1871053207
Name:HEINZ, BROOKE NICHOLLE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICHOLLE
Last Name:HEINZ
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 1:4 AGGIE VLG APT G
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2613
Mailing Address - Country:US
Mailing Address - Phone:801-419-7536
Mailing Address - Fax:
Practice Address - Street 1:471 HERITAGE PARK BLVD STE 5
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5623
Practice Address - Country:US
Practice Address - Phone:801-217-3390
Practice Address - Fax:844-854-4658
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist