Provider Demographics
NPI:1710106489
Name:BROCA LIFE OPTIONS LLC
Entity Type:Organization
Organization Name:BROCA LIFE OPTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:L EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN CABEZUDO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:480-557-5710
Mailing Address - Street 1:3941 E CHANDLER BLVD
Mailing Address - Street 2:STE. 106-158
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0301
Mailing Address - Country:US
Mailing Address - Phone:480-557-5710
Mailing Address - Fax:480-557-5712
Practice Address - Street 1:1492 S MILL AVE
Practice Address - Street 2:STE. 114
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5652
Practice Address - Country:US
Practice Address - Phone:480-557-5710
Practice Address - Fax:480-557-5712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3576103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ700885-000OtherMAGELLAN
AZ8951723OtherCIGNA #
AZAZ0618080OtherBCBSAZ
AZ700885000OtherMAGELLAN
AZZ85734Medicare PIN
AZY22335Medicare UPIN