Provider Demographics
NPI:1548956931
Name:BROWN, BRODERICK HOLLISTER (APCC)
Entity type:Individual
Prefix:
First Name:BRODERICK
Middle Name:HOLLISTER
Last Name:BROWN
Suffix:
Gender:M
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 E COLORADO BLVD
Mailing Address - Street 2:PO BOX #60004
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106
Mailing Address - Country:US
Mailing Address - Phone:626-390-2535
Mailing Address - Fax:
Practice Address - Street 1:1355 S HILL ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3012
Practice Address - Country:US
Practice Address - Phone:323-644-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10503101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional