Provider Demographics
NPI:1205987054
Name:BROMBEREK, CAROL JEAN (PT)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:JEAN
Last Name:BROMBEREK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 W MOFFAT ST APT 105
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4389
Mailing Address - Country:US
Mailing Address - Phone:773-292-0312
Mailing Address - Fax:
Practice Address - Street 1:2930 S MICHIGAN AVE STE 107
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3270
Practice Address - Country:US
Practice Address - Phone:312-842-3919
Practice Address - Fax:312-842-3914
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist