Provider Demographics
NPI:1902034085
Name:BOOMER, DANIELLE RENE (DPT)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:RENE
Last Name:BOOMER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:DANIELLE
Other - Middle Name:RENE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:230 CLEARFIELD AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3383
Mailing Address - Fax:757-321-3332
Practice Address - Street 1:733 VOLVO PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1609
Practice Address - Country:US
Practice Address - Phone:757-321-3383
Practice Address - Fax:757-321-3332
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05501OtherMEDICARE GROUP