Healthcare Provider Details

I. General information

NPI: 1295253805
Provider Name (Legal Business Name): BROADUS INTERNATIONAL GROUP NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2017
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 COLISEUM CROSSING #5050
HAMPTON VA
23666-5971
US

IV. Provider business mailing address

110 COLISEUM XING # 5050
HAMPTON VA
23666-5971
US

V. Phone/Fax

Practice location:
  • Phone: 757-785-4424
  • Fax: 757-785-4424
Mailing address:
  • Phone: 757-778-9800
  • Fax: 757-778-9899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberS6963161
License Number StateVA

VIII. Authorized Official

Name: KATESHA BROADUS
Title or Position: CEO/FOUNDER
Credential:
Phone: 240-447-2505