Provider Demographics
NPI:1659007961
Name:BROCKENBAUGH, AJANNA
Entity Type:Individual
Prefix:
First Name:AJANNA
Middle Name:
Last Name:BROCKENBAUGH
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 1:4 LEAWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRIARCLIFF MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10510-1316
Mailing Address - Country:US
Mailing Address - Phone:646-872-4645
Mailing Address - Fax:
Practice Address - Street 1:4 LEAWOOD DR
Practice Address - Street 2:
Practice Address - City:BRIARCLIFF MANOR
Practice Address - State:NY
Practice Address - Zip Code:10510-1316
Practice Address - Country:US
Practice Address - Phone:646-872-4645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP116161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health