Provider Demographics
NPI:1104692524
Name:BROUILLET, GEORGE H (AMFT)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:H
Last Name:BROUILLET
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20051 SW BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1719
Mailing Address - Country:US
Mailing Address - Phone:949-490-4052
Mailing Address - Fax:949-490-4053
Practice Address - Street 1:20051 SW BIRCH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1719
Practice Address - Country:US
Practice Address - Phone:949-490-4052
Practice Address - Fax:949-490-4053
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142092106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist