MEDICARE: GEAVANYA BROOMFIELD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355S0801X	Speech-Language Assistant	SI2508	FL
2	103K00000X	Behavior Analyst	1-21-56511	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	SI2508	OTHER	FL	SI2508

General Provider Information

NPI Number	:	1548716376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEAVANYA BROOMFIELD

Provider Business Mailing Address
First Line	:	4667 GARDENS PARK BLVD APT 1204
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32839-2424
Country	:	US
Telephone Number	:	407-455-2105
Fax Number	:

Provider Business Practice Location Address
First Line	:	5798 S SEMORAN BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-4819
Country	:	US
Telephone Number	:	407-455-2105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	12/14/2023

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Directions to “ GEAVANYA BROOMFIELD ” Practice Location

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