Provider Demographics
NPI:1588179519
Name:BROEKEMA, BETHANY LYNN
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:LYNN
Last Name:BROEKEMA
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 1:911 HACIENDA DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6407
Mailing Address - Country:US
Mailing Address - Phone:760-216-6942
Mailing Address - Fax:
Practice Address - Street 1:911 HACIENDA DR STE B
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6503
Practice Address - Country:US
Practice Address - Phone:760-216-6942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician