Provider Demographics
NPI:1285921643
Name:BRODERICK, DUANE
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:
Last Name:BRODERICK
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 1:2311 PARKE AVE., STE. 8
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83350
Mailing Address - Country:US
Mailing Address - Phone:208-878-3350
Mailing Address - Fax:208-878-3351
Practice Address - Street 1:2311 PARKE AVE., STE. 8
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83350
Practice Address - Country:US
Practice Address - Phone:208-878-3350
Practice Address - Fax:208-878-3351
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW3064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health