Provider Demographics
NPI:1215339650
Name:DARRELL BROADDUS PSYCHOLOGICAL SERVICES PC
Entity type:Organization
Organization Name:DARRELL BROADDUS PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADDUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-412-4270
Mailing Address - Street 1:PO BOX 750834
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-0834
Mailing Address - Country:US
Mailing Address - Phone:718-268-6600
Mailing Address - Fax:718-268-6065
Practice Address - Street 1:6128 VIA PRESIDIO
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-4460
Practice Address - Country:US
Practice Address - Phone:916-412-4270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 20101OtherCALIFORNIA LICENSE