Doctor Name: | DUANE BRODERICK |
NPI Number: | 1285921643 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | LMSW3064 |
Business Practice Address: | 2311 Parke Ave., Ste. 8 Burley, ID - 83350 |
Business Phone Number: | 2088783350 |
Business Fax Number: | 2088783351 |
Mailing Address: | 2311 Parke Ave., Ste. 8, BURLEY |
State: | ID |
Postal Code: | 83350 |
Phone Number: | 2088783350 |
Fax Number: | 2088783351 |
NPI Enumeration Date: | 07/06/2011 |
NPI Last Update Date: | 07/06/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | LMSW3064 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ID |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |