Provider Demographics
NPI:1649437104
Name:BROTHERS, THEDA (FP)
Entity type:Individual
Prefix:
First Name:THEDA
Middle Name:
Last Name:BROTHERS
Suffix:
Gender:F
Credentials:FP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6211 S 21ST ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-4645
Mailing Address - Country:US
Mailing Address - Phone:602-276-5894
Mailing Address - Fax:
Practice Address - Street 1:6211 S 21ST ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-4645
Practice Address - Country:US
Practice Address - Phone:602-276-5894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker