Provider Demographics
NPI:1790324366
Name:BROTHERTON, GARLAND EDWARD
Entity Type:Individual
Prefix:MR
First Name:GARLAND
Middle Name:EDWARD
Last Name:BROTHERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5059 QUAIL RUN RD APT 160
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6487
Mailing Address - Country:US
Mailing Address - Phone:951-966-4501
Mailing Address - Fax:
Practice Address - Street 1:3625 14TH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3815
Practice Address - Country:US
Practice Address - Phone:951-358-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician