Provider Demographics
NPI:1376416545
Name:BRODERICK, TRISHA (LPN)
Entity type:Individual
Prefix:MS
First Name:TRISHA
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 E FOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-4607
Mailing Address - Country:US
Mailing Address - Phone:719-960-9216
Mailing Address - Fax:
Practice Address - Street 1:5360 N ACADEMY BLVD STE 290
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4038
Practice Address - Country:US
Practice Address - Phone:719-434-2061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO03323232083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1BGTSP9Medicaid