Provider Demographics
NPI:1538767322
Name:BROOME, MARY LYNN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY LYNN
Middle Name:
Last Name:BROOME
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9281 SUMPTER RD
Mailing Address - Street 2:
Mailing Address - City:MAYBEE
Mailing Address - State:MI
Mailing Address - Zip Code:48159-9613
Mailing Address - Country:US
Mailing Address - Phone:734-735-7391
Mailing Address - Fax:
Practice Address - Street 1:9281 SUMPTER RD
Practice Address - Street 2:
Practice Address - City:MAYBEE
Practice Address - State:MI
Practice Address - Zip Code:48159-9613
Practice Address - Country:US
Practice Address - Phone:734-735-7391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101007235235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist