Provider Demographics
NPI:1750896288
Name:BROOM, WILFRED CARNELL
Entity type:Individual
Prefix:MR
First Name:WILFRED
Middle Name:CARNELL
Last Name:BROOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7171 BOWLING DRIVE SUITE 300
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823
Mailing Address - Country:US
Mailing Address - Phone:916-394-9195
Mailing Address - Fax:916-392-2827
Practice Address - Street 1:7171 BOWLING DRIVE SUITE 300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823
Practice Address - Country:US
Practice Address - Phone:916-394-9195
Practice Address - Fax:916-392-2827
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508011065Medicaid