Basic Information
| Provider Information | |||||||||
| NPI: | 1245376474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROMELOW | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | SOFER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOFER | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | ANNIE LOU | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 58 WAYLAND RD | ||||||||
| Address2: | |||||||||
| City: | PARADISE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959696135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303216439 | ||||||||
| FaxNumber: | 5308776787 | ||||||||
| Practice Location | |||||||||
| Address1: | 7200 SKYWAY | ||||||||
| Address2: | |||||||||
| City: | PARADISE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959693280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308776764 | ||||||||
| FaxNumber: | 5308776787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YS0200X | CA | N | Behavioral Health & Social Service Providers | Counselor | School | 225C00000X | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor | 104100000X | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.