Provider Demographics
NPI:1851721682
Name:BROKER, MIA (BCBA)
Entity Type:Individual
Prefix:MS
First Name:MIA
Middle Name:
Last Name:BROKER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 OAKDALE AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-6515
Mailing Address - Country:US
Mailing Address - Phone:304-867-4070
Mailing Address - Fax:
Practice Address - Street 1:9301 OAKDALE AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-6515
Practice Address - Country:US
Practice Address - Phone:304-867-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-14482103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst