Provider Demographics
NPI:1598462145
Name:BALCONI-BROOME, MARY SUZANNE (OTR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUZANNE
Last Name:BALCONI-BROOME
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 LAS COLINAS BLVD E APT 379
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-6214
Mailing Address - Country:US
Mailing Address - Phone:817-475-3124
Mailing Address - Fax:
Practice Address - Street 1:377 LAS COLINAS BLVD E APT 379
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-6214
Practice Address - Country:US
Practice Address - Phone:817-475-3124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108777225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist