Provider Demographics
NPI:1861977530
Name:BROOMELL, TRACY (DPT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BROOMELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7614 RAVENSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5020
Mailing Address - Country:US
Mailing Address - Phone:269-501-8640
Mailing Address - Fax:
Practice Address - Street 1:4025 CHERRY AVE NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4859
Practice Address - Country:US
Practice Address - Phone:503-390-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018836225100000X
OR62970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist