Provider Demographics
NPI:1336581404
Name:BROOMBERG, LOLA MADRONE (LPC)
Entity Type:Individual
Prefix:MS
First Name:LOLA
Middle Name:MADRONE
Last Name:BROOMBERG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 WILLAMETTE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2687
Mailing Address - Country:US
Mailing Address - Phone:541-341-3477
Mailing Address - Fax:
Practice Address - Street 1:541 WILLAMETTE ST STE 207A
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2623
Practice Address - Country:US
Practice Address - Phone:541-686-8119
Practice Address - Fax:541-686-3340
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3168101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500692264Medicaid