Provider Demographics
NPI:1336241637
Name:BROADWATER, CHRISTINE (LPC)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 MARTY LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-7076
Mailing Address - Country:US
Mailing Address - Phone:336-470-1668
Mailing Address - Fax:
Practice Address - Street 1:122 N ELM ST
Practice Address - Street 2:SUITE 1015
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2878
Practice Address - Country:US
Practice Address - Phone:336-676-6064
Practice Address - Fax:336-676-6068
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC852101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103336Medicaid