=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902250806
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CATHERINE BROCCOLI, LMFT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2016
-----------------------------------------------------
Last Update Date | 04/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13 KILLIAN LN
-----------------------------------------------------
City | BREWSTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10509-2851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-589-7435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 734
-----------------------------------------------------
City | BREWSTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10509-0734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-589-7435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | CATHERINE BROCCOLI
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 914-589-7435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 000854-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------