Healthcare Provider Details

I. General information

NPI: 1871036194
Provider Name (Legal Business Name): U.S. AIR FORCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2016
Last Update Date: 11/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 JULIAN LN
FAIRFIELD CA
94534-3131
US

IV. Provider business mailing address

2323 JULIAN LN
FAIRFIELD CA
94534-3131
US

V. Phone/Fax

Practice location:
  • Phone: 301-633-9503
  • Fax:
Mailing address:
  • Phone: 301-633-9503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberR190890
License Number StateMD

VIII. Authorized Official

Name: DR. RACHEL ANNE BROUSSARD
Title or Position: PMHNP
Credential: DNP
Phone: 301-633-9503