Provider Demographics
NPI:1225868797
Name:BROADWELL, CLAY BURT
Entity type:Individual
Prefix:
First Name:CLAY
Middle Name:BURT
Last Name:BROADWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 S 12TH ST APT 137
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-3144
Mailing Address - Country:US
Mailing Address - Phone:701-840-1506
Mailing Address - Fax:
Practice Address - Street 1:2130 S 12TH ST APT 137
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-3144
Practice Address - Country:US
Practice Address - Phone:701-840-1506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health