Provider Demographics
NPI:1548716376
Name:BROOMFIELD, GEAVANYA
Entity type:Individual
Prefix:
First Name:GEAVANYA
Middle Name:
Last Name:BROOMFIELD
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 1:4667 GARDENS PARK BLVD APT 1204
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-2424
Mailing Address - Country:US
Mailing Address - Phone:407-455-2105
Mailing Address - Fax:
Practice Address - Street 1:5798 S SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-4819
Practice Address - Country:US
Practice Address - Phone:407-455-2105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI25082355S0801X
FL1-21-56511103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113378200Medicaid
FLSI2508OtherSI2508