Healthcare Provider Details

I. General information

NPI: 1780624650
Provider Name (Legal Business Name): KAREN HARTEN BROIDA MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: KAREN GRODY MFT

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE SUITE 970
LA JOLLA CA
92037-1234
US

IV. Provider business mailing address

PO BOX 609001
SAN DIEGO CA
92160-9001
US

V. Phone/Fax

Practice location:
  • Phone: 858-558-2731
  • Fax: 858-452-5905
Mailing address:
  • Phone: 619-528-4600
  • Fax: 619-528-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC25550
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: