Provider Demographics
NPI:1902175250
Name:BROADHURST, AMY D
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:D
Last Name:BROADHURST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 DIAMOND VALLEY RD UNIT C
Mailing Address - Street 2:
Mailing Address - City:MARKLEEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96120-9579
Mailing Address - Country:US
Mailing Address - Phone:530-694-1816
Mailing Address - Fax:530-694-2387
Practice Address - Street 1:75 DIAMOND VALLEY RD UNIT C
Practice Address - Street 2:
Practice Address - City:MARKLEEVILLE
Practice Address - State:CA
Practice Address - Zip Code:96120-9579
Practice Address - Country:US
Practice Address - Phone:530-694-1816
Practice Address - Fax:530-694-2387
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor