Provider Demographics
NPI:1417162942
Name:BROCE, EDITH E
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:E
Last Name:BROCE
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 25
Mailing Address - Street 2:
Mailing Address - City:DUNSMUIR
Mailing Address - State:CA
Mailing Address - Zip Code:96025-0025
Mailing Address - Country:US
Mailing Address - Phone:530-841-4100
Mailing Address - Fax:530-841-4781
Practice Address - Street 1:2060 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9538
Practice Address - Country:US
Practice Address - Phone:530-841-4100
Practice Address - Fax:530-841-4781
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF44237106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist