Provider Demographics
NPI:1316502495
Name:BROUSSEAU, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:BROUSSEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:DRABICKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:43195 AVENIDA DE SAN PASQUAL
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-3121
Mailing Address - Country:US
Mailing Address - Phone:702-379-8846
Mailing Address - Fax:
Practice Address - Street 1:24977 WASHINGTON AVE # K
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9832
Practice Address - Country:US
Practice Address - Phone:951-677-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-05
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97499106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist