Healthcare Provider Details

I. General information

NPI: 1790324366
Provider Name (Legal Business Name): MR. GARLAND EDWARD BROTHERTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 04/28/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 14TH ST
RIVERSIDE CA
92501-3815
US

IV. Provider business mailing address

5059 QUAIL RUN RD APT 160
RIVERSIDE CA
92507-6487
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-6680
  • Fax:
Mailing address:
  • Phone: 951-966-4501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: