Healthcare Provider Details

I. General information

NPI: 1013473446
Provider Name (Legal Business Name): AARON BROADUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 1ST ST
WOODLAND CA
95695-4023
US

IV. Provider business mailing address

455 1ST ST
WOODLAND CA
95695-4023
US

V. Phone/Fax

Practice location:
  • Phone: 530-662-2211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number109356
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number109356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: