Provider Demographics
NPI:1043794431
Name:BROOM, INDIA E
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:E
Last Name:BROOM
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 1:1111 E BROWN RD APT 205
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-4966
Mailing Address - Country:US
Mailing Address - Phone:480-553-0579
Mailing Address - Fax:
Practice Address - Street 1:1166 S GILBERT RD STE 106
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3461
Practice Address - Country:US
Practice Address - Phone:602-535-8341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician