Provider Demographics
NPI:1619090669
Name:JAMES BROECKER PA
Entity type:Organization
Organization Name:JAMES BROECKER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LIC. MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:BROECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT
Authorized Official - Phone:651-295-2409
Mailing Address - Street 1:2806 ITASCA AVE S
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MN
Mailing Address - Zip Code:55043-9741
Mailing Address - Country:US
Mailing Address - Phone:715-531-6760
Mailing Address - Fax:715-531-6761
Practice Address - Street 1:901 DOMINION DR
Practice Address - Street 2:HUDSON COUNSELING
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9326
Practice Address - Country:US
Practice Address - Phone:715-531-6760
Practice Address - Fax:715-531-6761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health