Provider Demographics
NPI:1669460762
Name:BROEGE, PHYLLIS (PHD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BROEGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK ST
Mailing Address - Street 2:GLENS FALLS HOSPITAL
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-7200
Mailing Address - Fax:518-926-7036
Practice Address - Street 1:2 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1702
Practice Address - Country:US
Practice Address - Phone:518-926-2000
Practice Address - Fax:518-926-2020
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013412103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY680014530OtherRR MEDICARE
NY02070735Medicaid
NY02070735Medicaid
NYCC7485Medicare PIN