Provider Demographics
NPI:1275284135
Name:FENTON, BROCHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BROCHA
Middle Name:
Last Name:FENTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 OAKFORD ST
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-3255
Mailing Address - Country:US
Mailing Address - Phone:917-755-6695
Mailing Address - Fax:
Practice Address - Street 1:301 OAKFORD ST
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-3255
Practice Address - Country:US
Practice Address - Phone:917-755-6695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018964103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical