1477087633 NPI number — MARCELLUS E BROOMES, MS LAC, LCADC

Table of content: MARCELLUS E BROOMES, MS LAC, LCADC (NPI 1477087633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477087633 NPI number — MARCELLUS E BROOMES, MS LAC, LCADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOMES, MS
Provider First Name:
MARCELLUS
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC, LCADC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROOMES
Provider Other First Name:
MARCELLUS
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LAC, LCADC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1477087633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
492 ROUTE 57 WEST
Provider Second Line Business Mailing Address:
FAMILY GUIDANCE CENTER OF WARREN COUNTY
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07882-4411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-689-1000
Provider Business Mailing Address Fax Number:
908-689-4529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 MEMORIAL PARKWAY
Provider Second Line Business Practice Location Address:
FAMILY GUIDANCE CENTER OF WARREN COUNTY
Provider Business Practice Location Address City Name:
PHILLIPSBURG
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08865-1580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-454-4470
Provider Business Practice Location Address Fax Number:
908-454-5317
Provider Enumeration Date:
04/14/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  37AC00232200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 37LC00206800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)