Healthcare Provider Details

I. General information

NPI: 1669919064
Provider Name (Legal Business Name): EMILY BROADHURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 W 10TH ST
ANTIOCH CA
94509-1653
US

IV. Provider business mailing address

427 E CENTURY BLVD
LODI CA
95240-8810
US

V. Phone/Fax

Practice location:
  • Phone: 925-777-9540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY34627
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY34627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: