Provider Demographics
NPI:1194781765
Name:BROADUS, MARIAN JUDITH (PH D)
Entity type:Individual
Prefix:DR
First Name:MARIAN
Middle Name:JUDITH
Last Name:BROADUS
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40507-1040
Mailing Address - Country:US
Mailing Address - Phone:859-231-7137
Mailing Address - Fax:859-253-0098
Practice Address - Street 1:436 W 2ND ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40507-1040
Practice Address - Country:US
Practice Address - Phone:859-231-7137
Practice Address - Fax:859-253-0098
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY834103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCP00050Medicare PIN