Provider Demographics
NPI:1225088545
Name:BROOME, CASEY (LMT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:BROOME
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16169 SE 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9699
Mailing Address - Country:US
Mailing Address - Phone:503-784-5623
Mailing Address - Fax:
Practice Address - Street 1:16169 SE 106TH AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9699
Practice Address - Country:US
Practice Address - Phone:503-784-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10100225700000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist