Provider Demographics
NPI:1902957137
Name:BROLAN, DAVID JOHN (PHD, LCSW, CEAP)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:BROLAN
Suffix:
Gender:M
Credentials:PHD, LCSW, CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 CLAY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1191
Mailing Address - Country:US
Mailing Address - Phone:570-961-5947
Mailing Address - Fax:570-558-0777
Practice Address - Street 1:1141 CLAY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18510-1191
Practice Address - Country:US
Practice Address - Phone:570-961-5947
Practice Address - Fax:570-558-0777
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW002484L101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA645978Medicare ID - Type Unspecified
PAR08158Medicare UPIN