Provider Demographics
NPI:1508343278
Name:BROGLA, KATHLEEN MARIE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BROGLA
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 1:4050 BOWLING ST SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-5005
Mailing Address - Country:US
Mailing Address - Phone:319-862-1050
Mailing Address - Fax:
Practice Address - Street 1:4050 BOWLING ST SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-5005
Practice Address - Country:US
Practice Address - Phone:319-270-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)