Healthcare Provider Details

I. General information

NPI: 1750412102
Provider Name (Legal Business Name): ANNE BROADUS HOLDING LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 NORTH MAIN ST ---
ALTURAS CA
96101-4113
US

IV. Provider business mailing address

441 N. MAIN STREET
ALTURAS CA
96101
US

V. Phone/Fax

Practice location:
  • Phone: 530-233-6312
  • Fax: 530-233-6339
Mailing address:
  • Phone: 530-233-6312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF99575
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number123367
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: