Provider Demographics
NPI:1669844668
Name:BROUS, DIANE (MA SPECIAL ED)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BROUS
Suffix:
Gender:F
Credentials:MA SPECIAL ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 E BROADWAY
Mailing Address - Street 2:APT 7H
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4758
Mailing Address - Country:US
Mailing Address - Phone:516-287-7084
Mailing Address - Fax:
Practice Address - Street 1:854 E BROADWAY APT 7H
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-4733
Practice Address - Country:US
Practice Address - Phone:516-897-0412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY103K00000XOtherEDUCATIONAL AGENCY