MEDICARE: MARIA LYNN BROCKMAN MFT

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	106H00000X	Marriage & Family Therapist	MFC45127	CA

General Provider Information

NPI Number	:	1598937690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA LYNN BROCKMAN MFT

Provider Business Mailing Address
First Line	:	PO BOX 22691
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92192-2691
Country	:	US
Telephone Number	:	858-401-3760
Fax Number	:

Provider Business Practice Location Address
First Line	:	4901 MORENA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-3423
Country	:	US
Telephone Number	:	858-401-3760
Fax Number	:

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

Provider Enumeration Date	:	03/28/2008
Last Update Date	:	03/11/2013

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