Healthcare Provider Details

I. General information

NPI: 1205407970
Provider Name (Legal Business Name): WILLOW NICOLE BROADDUS LCMHC, LPC, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2021
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 OLD STAGE RD
GRANVILLE VT
05747-9675
US

IV. Provider business mailing address

PO BOX 165
HANCOCK VT
05748-0165
US

V. Phone/Fax

Practice location:
  • Phone: 802-565-7124
  • Fax:
Mailing address:
  • Phone: 802-565-7124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0134330
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: