Provider Demographics
NPI:1316083728
Name:FAMILY RESOURCE CENTER 0384
Entity type:Organization
Organization Name:FAMILY RESOURCE CENTER 0384
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST (DIRECTOR)
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROADBENT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:602-866-3432
Mailing Address - Street 1:2432 W, PEORIA AVENUE
Mailing Address - Street 2:SUITE 1327
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029
Mailing Address - Country:US
Mailing Address - Phone:602-866-3432
Mailing Address - Fax:602-866-3764
Practice Address - Street 1:2432 W, PEORIA AVENUE
Practice Address - Street 2:SUITE 1327
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029
Practice Address - Country:US
Practice Address - Phone:602-866-3432
Practice Address - Fax:602-866-3764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC2693101Y00000X
AZLMFT10254106H00000X
AZ903103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZPHD903Medicare UPIN