Provider Demographics
NPI:1033710157
Name:BROTHERS, IDA
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:BROTHERS
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 1:2705 W 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-2222
Mailing Address - Country:US
Mailing Address - Phone:907-250-7793
Mailing Address - Fax:
Practice Address - Street 1:2705 W 67TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-2222
Practice Address - Country:US
Practice Address - Phone:907-250-0840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health