Provider Demographics
NPI:1184216582
Name:BROOME, LORETTA GAIL (PT)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:GAIL
Last Name:BROOME
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 OAK TREE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-9413
Mailing Address - Country:US
Mailing Address - Phone:864-275-1622
Mailing Address - Fax:
Practice Address - Street 1:1920 OAK TREE LN
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-9413
Practice Address - Country:US
Practice Address - Phone:864-275-1622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty