Provider Demographics
NPI:1992268973
Name:BROAD, MARIA GUADALUPE
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:GUADALUPE
Last Name:BROAD
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 1:4701 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-2263
Mailing Address - Country:US
Mailing Address - Phone:562-203-9314
Mailing Address - Fax:
Practice Address - Street 1:1926 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2402
Practice Address - Country:US
Practice Address - Phone:213-353-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)