MEDICARE: KIM RAE BROUHARD LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1485	OR

General Provider Information

NPI Number	:	1275657306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM RAE BROUHARD LCSW

Provider Business Mailing Address
First Line	:	1448 NW HAWTHORNE AVE
Second Line	:
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-1214
Country	:	US
Telephone Number	:	541-218-1421
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 NE 7TH ST
Second Line	:	SUITE C
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-1451
Country	:	US
Telephone Number	:	541-955-2566
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	07/08/2007

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