Provider Demographics
NPI:1962772129
Name:BRODERICK, KRISTIN KATHLEEN (LCM)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:KATHLEEN
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LCM
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:KATHLEEN
Other - Last Name:CASSIDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10400 RIDGLAND ROAD
Mailing Address - Street 2:STE 1
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030
Mailing Address - Country:US
Mailing Address - Phone:410-628-6120
Mailing Address - Fax:410-628-9825
Practice Address - Street 1:100 OWINGS COURT
Practice Address - Street 2:SUITE 8
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136
Practice Address - Country:US
Practice Address - Phone:410-526-7100
Practice Address - Fax:410-526-7138
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000635106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist