Provider Demographics
NPI:1881168607
Name:BROOM, TITUS V (CSAC-R)
Entity type:Individual
Prefix:
First Name:TITUS
Middle Name:V
Last Name:BROOM
Suffix:
Gender:M
Credentials:CSAC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 CRICKLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8525
Mailing Address - Country:US
Mailing Address - Phone:980-422-9653
Mailing Address - Fax:
Practice Address - Street 1:2211 W MOREHEAD ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5143
Practice Address - Country:US
Practice Address - Phone:980-422-9653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)