Healthcare Provider Details

I. General information

NPI: 1487251864
Provider Name (Legal Business Name): KEVIN THOMAS BRODERICK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 NORTH ST
AUBURN NY
13021-1826
US

IV. Provider business mailing address

684 OBRIEN HILL RD
RICHFORD NY
13835-1019
US

V. Phone/Fax

Practice location:
  • Phone: 315-252-3074
  • Fax:
Mailing address:
  • Phone: 914-523-4838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100984-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: