Provider Demographics
NPI:1710012836
Name:BROOME, REBECCA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:BROOME
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BONTUMASI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10335 CEDARCREST RD
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9396
Mailing Address - Country:US
Mailing Address - Phone:810-207-5725
Mailing Address - Fax:
Practice Address - Street 1:8010 GRAND RIVER RD STE 100
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9303
Practice Address - Country:US
Practice Address - Phone:810-207-5725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010885071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI730195Medicaid
MI382143740OtherTAX ID NUMBER
MI382143740OtherTAX ID NUMBER