MEDICARE: MACKENZIE ELLEN BROOM

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1083540512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE ELLEN BROOM

Provider Business Mailing Address
First Line	:	729 TIMMONS CT
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23322-3853
Country	:	US
Telephone Number	:	757-567-1704
Fax Number	:

Provider Business Practice Location Address
First Line	:	641 CARRIAGE HILL RD STE 200
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-6546
Country	:	US
Telephone Number	:	757-263-2800
Fax Number	:

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

Provider Enumeration Date	:	06/22/2026
Last Update Date	:	06/22/2026

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Directions to “ MACKENZIE ELLEN BROOM ” Practice Location

Language	Start Address	Practice Location

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