Healthcare Provider Details

I. General information

NPI: 1184810897
Provider Name (Legal Business Name): JULIE BROOM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18945 FM 2252 SUITE 115
GARDEN RIDGE TX
78266-2562
US

IV. Provider business mailing address

18945 FM 2252 SUITE 115
GARDEN RIDGE TX
78266-2562
US

V. Phone/Fax

Practice location:
  • Phone: 210-564-6602
  • Fax: 210-651-0029
Mailing address:
  • Phone: 210-564-6602
  • Fax: 210-651-0029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1222-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: