Provider Demographics
NPI:1336968882
Name:BROADBENT, MARC PATRICK
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:PATRICK
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:PATRICK
Other - Last Name:BROADBENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:205 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-1352
Mailing Address - Country:US
Mailing Address - Phone:856-857-8520
Mailing Address - Fax:
Practice Address - Street 1:1919 KINGS HWY FL 2
Practice Address - Street 2:
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-1619
Practice Address - Country:US
Practice Address - Phone:800-845-0336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00810800101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor