Provider Demographics
NPI:1245289347
Name:FOWKES, BRANDELYN GILLEAS (MS CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:BRANDELYN
Middle Name:GILLEAS
Last Name:FOWKES
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MISS
Other - First Name:BRANDELYN
Other - Middle Name:GILLEAS
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:2320 RIVERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-2240
Mailing Address - Country:US
Mailing Address - Phone:541-731-1794
Mailing Address - Fax:
Practice Address - Street 1:1500 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3705
Practice Address - Country:US
Practice Address - Phone:541-485-8521
Practice Address - Fax:541-485-6159
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12644235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist