Healthcare Provider Details

I. General information

NPI: 1437504362
Provider Name (Legal Business Name): COLEEN BROAD CERTIFICATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18205 SE 12TH CIR
VANCOUVER WA
98683-5541
US

IV. Provider business mailing address

18205 SE 12TH CIR
VANCOUVER WA
98683-5541
US

V. Phone/Fax

Practice location:
  • Phone: 360-892-5524
  • Fax:
Mailing address:
  • Phone: 360-892-5524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: