Provider Demographics
NPI:1144362914
Name:BROENEN, ROBERT ARTHUR (PSYD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ARTHUR
Last Name:BROENEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 AVENIDA CABRILLO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4040
Mailing Address - Country:US
Mailing Address - Phone:949-542-9052
Mailing Address - Fax:949-542-3280
Practice Address - Street 1:161 AVENIDA CABRILLO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4040
Practice Address - Country:US
Practice Address - Phone:949-542-9052
Practice Address - Fax:949-542-3280
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13147103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL13147OtherTRIWEST