Provider Demographics
NPI:1316205503
Name:BRONDSEMA, CAROL LYN (MS,BA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYN
Last Name:BRONDSEMA
Suffix:
Gender:F
Credentials:MS,BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 BAY AREA BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2538
Mailing Address - Country:US
Mailing Address - Phone:281-488-7221
Mailing Address - Fax:
Practice Address - Street 1:1234 BAY AREA BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2538
Practice Address - Country:US
Practice Address - Phone:281-488-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist