Healthcare Provider Details

I. General information

NPI: 1588179519
Provider Name (Legal Business Name): BETHANY LYNN BROEKEMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 01/11/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 HACIENDA DR STE B
VISTA CA
92081-6503
US

IV. Provider business mailing address

911 HACIENDA DR
VISTA CA
92081-6407
US

V. Phone/Fax

Practice location:
  • Phone: 760-216-6942
  • Fax:
Mailing address:
  • Phone: 760-216-6942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: