Provider Demographics
NPI:1639955917
Name:BROOME, SHARISSE
Entity Type:Individual
Prefix:
First Name:SHARISSE
Middle Name:
Last Name:BROOME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E SPAULDING AVE UNIT D18
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81007-5611
Mailing Address - Country:US
Mailing Address - Phone:719-406-6892
Mailing Address - Fax:
Practice Address - Street 1:1930 FREQUENT FLYER PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-1500
Practice Address - Country:US
Practice Address - Phone:719-579-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician