MEDICARE: MRS. WILLOW NICOLE BROADDUS LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	068.0134330	VT

General Provider Information

NPI Number	:	1205407970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. WILLOW NICOLE BROADDUS LCMHC

Provider Business Mailing Address
First Line	:	87 BONNYVALE RD
Second Line	:
City	:	BRATTLEBORO
State	:	VT
Zip	:	05301-2548
Country	:	US
Telephone Number	:	802-565-7124
Fax Number	:

Provider Business Practice Location Address
First Line	:	87 BONNYVALE RD
Second Line	:
City	:	BRATTLEBORO
State	:	VT
Zip	:	05301-2548
Country	:	US
Telephone Number	:	802-565-7124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2021
Last Update Date	:	05/27/2026

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