Healthcare Provider Details

I. General information

NPI: 1154694792
Provider Name (Legal Business Name): BROM GLIDDEN M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 N CENTER VALLEY RD
SANDPOINT ID
83864-7148
US

IV. Provider business mailing address

534 N CENTER VALLEY RD
SANDPOINT ID
83864-7148
US

V. Phone/Fax

Practice location:
  • Phone: 208-597-0994
  • Fax:
Mailing address:
  • Phone: 208-597-0994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCP-4881
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: