Healthcare Provider Details

I. General information

NPI: 1730714247
Provider Name (Legal Business Name): TINA MARIE BROADSWORD LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14950 N COEUR DALENE ST
RATHDRUM ID
83858-6484
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-687-0538
  • Fax: 208-687-3185
Mailing address:
  • Phone: 208-625-4700
  • Fax: 208-625-4701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW37001
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW37001
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: