Provider Demographics
NPI:1568299279
Name:BRODERICK, MICHELLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WILLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:2103 AGECROFT RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-5825
Mailing Address - Country:US
Mailing Address - Phone:757-754-6980
Mailing Address - Fax:
Practice Address - Street 1:2103 AGECROFT RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5825
Practice Address - Country:US
Practice Address - Phone:757-754-6980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003837235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist