Provider Demographics
NPI:1174251219
Name:BROMLEY, RAEGAN
Entity type:Individual
Prefix:
First Name:RAEGAN
Middle Name:
Last Name:BROMLEY
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 1:901 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-4819
Mailing Address - Country:US
Mailing Address - Phone:575-390-3461
Mailing Address - Fax:
Practice Address - Street 1:18 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-4023
Practice Address - Country:US
Practice Address - Phone:575-739-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCF7487235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist