Provider Demographics
NPI:1225383607
Name:BROBERG, EMILIA
Entity Type:Individual
Prefix:
First Name:EMILIA
Middle Name:
Last Name:BROBERG
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:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91012-0628
Mailing Address - Country:US
Mailing Address - Phone:626-755-8558
Mailing Address - Fax:626-755-8558
Practice Address - Street 1:1031 ALPINE VILLA DR
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-1404
Practice Address - Country:US
Practice Address - Phone:626-755-8558
Practice Address - Fax:626-755-8558
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2015-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-05-2148103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst