Provider Demographics
NPI:1194445908
Name:BROUGHTON, FAITH MARION
Entity type:Individual
Prefix:
First Name:FAITH
Middle Name:MARION
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1592 N GEMSTONE PL
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5469
Mailing Address - Country:US
Mailing Address - Phone:208-964-5592
Mailing Address - Fax:
Practice Address - Street 1:1592 N GEMSTONE PL
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5469
Practice Address - Country:US
Practice Address - Phone:208-964-5592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician