Provider Demographics
NPI:1073643623
Name:BROMBERG, ROBERT JEROME (BA, CDP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JEROME
Last Name:BROMBERG
Suffix:
Gender:M
Credentials:BA, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-7647
Mailing Address - Country:US
Mailing Address - Phone:360-400-2242
Mailing Address - Fax:360-400-2471
Practice Address - Street 1:306 2ND ST NE
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-7647
Practice Address - Country:US
Practice Address - Phone:360-400-2242
Practice Address - Fax:360-400-2471
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA34121200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)