Healthcare Provider Details

I. General information

NPI: 1881716942
Provider Name (Legal Business Name): TODD BRODERIUS LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 11TH AVE
LONGVIEW WA
98632-2555
US

IV. Provider business mailing address

945 11TH AVE
LONGVIEW WA
98632-2555
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-8600
  • Fax: 360-636-7372
Mailing address:
  • Phone: 360-414-8600
  • Fax: 360-636-7372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWI.LW.60064160
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: