Healthcare Provider Details

I. General information

NPI: 1063488245
Provider Name (Legal Business Name): WYNNE E. BROMS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 S SOLANO DR SUITE B
LAS CRUCES NM
88001-5406
US

IV. Provider business mailing address

782 WARM SANDS CT
LAS CRUCES NM
88011-0910
US

V. Phone/Fax

Practice location:
  • Phone: 575-525-2425
  • Fax:
Mailing address:
  • Phone: 575-525-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number529
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: