Basic Information
| Provider Information | |||||||||
| NPI: | 1952069890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROUHARD | ||||||||
| FirstName: | CRISTI | ||||||||
| MiddleName: | |||||||||
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| Credential: | RADT I | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1666 | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956671666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306269240 | ||||||||
| FaxNumber: | 5306422064 | ||||||||
| Practice Location | |||||||||
| Address1: | 2844 COLOMA ST | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956674406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306267252 | ||||||||
| FaxNumber: | 5306267934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2021 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1450931221 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.