Healthcare Provider Details

I. General information

NPI: 1114835824
Provider Name (Legal Business Name): DRUE GRAECYN BROTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 MARSH ST STE 1
SAN LUIS OBISPO CA
93401-3346
US

IV. Provider business mailing address

996 ROYAL MARCO WAY
MARCO ISLAND FL
34145-1829
US

V. Phone/Fax

Practice location:
  • Phone: 805-703-2120
  • Fax:
Mailing address:
  • Phone: 818-345-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberWDL36316D33B
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: