Provider Demographics
NPI:1750699211
Name:BROSAL, MARK ALAN (MA LPC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:BROSAL
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 URANUS ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4050
Mailing Address - Country:US
Mailing Address - Phone:970-215-6806
Mailing Address - Fax:970-282-3734
Practice Address - Street 1:317 URANUS ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4050
Practice Address - Country:US
Practice Address - Phone:970-215-6806
Practice Address - Fax:970-282-3734
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-18
Last Update Date:2010-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1317101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor