Provider Demographics
NPI:1477207884
Name:BROMLEY, BRILEE MADISON I
Entity Type:Individual
Prefix:MS
First Name:BRILEE
Middle Name:MADISON
Last Name:BROMLEY
Suffix:I
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:BRILEE
Other - Middle Name:BROMLEY
Other - Last Name:TEAGUE
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:MARRIED NAME
Mailing Address - Street 1:4897 MIDDLEBURG ROAD
Mailing Address - Street 2:
Mailing Address - City:DECATURVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38329
Mailing Address - Country:US
Mailing Address - Phone:173-154-9646
Mailing Address - Fax:
Practice Address - Street 1:2865 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343
Practice Address - Country:US
Practice Address - Phone:731-784-8405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3773224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant