Provider Demographics
NPI:1821237090
Name:BRONSTAD, DEBBRA
Entity Type:Individual
Prefix:
First Name:DEBBRA
Middle Name:
Last Name:BRONSTAD
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 1:1460 WALTON BLVD STE 218
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1779
Mailing Address - Country:US
Mailing Address - Phone:248-929-5354
Mailing Address - Fax:
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52836106H00000X
CO.0001320106H00000X
MI4101006638106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91892ZOtherMEDICARE GROUP PTAN ID#
CAZZZ91891ZOtherMEDICARE GROUP PTAN ID#
CAZZZ92069ZOtherMEDICARE GROUP PTAN ID#