Provider Demographics
NPI:1700296373
Name:BROMBERG, KELSIE ELIZABETH
Entity Type:Individual
Prefix:MISS
First Name:KELSIE
Middle Name:ELIZABETH
Last Name:BROMBERG
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 1:18 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5115
Mailing Address - Country:US
Mailing Address - Phone:508-446-4133
Mailing Address - Fax:
Practice Address - Street 1:18 NEWTON ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5115
Practice Address - Country:US
Practice Address - Phone:508-446-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1821159880104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker