Provider Demographics
NPI:1063059996
Name:PENCE, BROOKE CHASTAIN (MA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:CHASTAIN
Last Name:PENCE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5506
Mailing Address - Country:US
Mailing Address - Phone:714-871-5646
Mailing Address - Fax:
Practice Address - Street 1:505 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5506
Practice Address - Country:US
Practice Address - Phone:714-450-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124449106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist