Provider Demographics
NPI:1124897996
Name:WEBSTER, BRODERICK SR (LPC)
Entity type:Individual
Prefix:MR
First Name:BRODERICK
Middle Name:
Last Name:WEBSTER
Suffix:SR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38107-4611
Mailing Address - Country:US
Mailing Address - Phone:901-620-7289
Mailing Address - Fax:
Practice Address - Street 1:793 TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-2441
Practice Address - Country:US
Practice Address - Phone:731-228-9068
Practice Address - Fax:901-425-9773
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health