Basic Information
Provider Information | |||||||||
NPI: | 1962783688 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROMER | ||||||||
FirstName: | DENISE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3100 TRADITION CIR | ||||||||
Address2: |   | ||||||||
City: | MT PLEASANT | ||||||||
State: | SC | ||||||||
PostalCode: | 294667200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436547945 | ||||||||
FaxNumber: | 8438846481 | ||||||||
Practice Location | |||||||||
Address1: | 3100 TRADITION CIR | ||||||||
Address2: |   | ||||||||
City: | MT PLEASANT | ||||||||
State: | SC | ||||||||
PostalCode: | 294667200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436547945 | ||||||||
FaxNumber: | 8438846481 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2011 | ||||||||
LastUpdateDate: | 09/08/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 4296 | SC | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 351565294 | SC | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 4296 | 01 | SC | LICENSE # | OTHER |