Provider Demographics
NPI:1053542308
Name:BROSH, ANDRA
Entity type:Individual
Prefix:DR
First Name:ANDRA
Middle Name:
Last Name:BROSH
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 1:212 MARINE ST
Mailing Address - Street 2:#102
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-6509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 MARINE ST
Practice Address - Street 2:#102
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-6509
Practice Address - Country:US
Practice Address - Phone:310-922-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22901103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical