Provider Demographics
NPI:1225507916
Name:BROSIOUS, CAITLIN G
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:G
Last Name:BROSIOUS
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 1:1930 N VERMONT AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-1860
Mailing Address - Country:US
Mailing Address - Phone:847-420-2514
Mailing Address - Fax:
Practice Address - Street 1:1926 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2402
Practice Address - Country:US
Practice Address - Phone:214-353-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-25
Last Update Date:2018-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)