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General NPI Number Information
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NPI Number | 1013417195
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Entity Type | Individual
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Provider Name | MS. KENYA MARIE BROADNAX
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Gender | Female
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Dates
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Enumeration Date | 02/15/2018
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Last Update Date | 02/15/2018
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Provider Practice Location Address
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Address Line | 1033 SW 152ND ST
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City | BURIEN
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State | WA
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Zip | 98166-1845
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Country | US
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Telephone | 206-242-1126
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Fax | 206-829-1258
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Provider Business Mailing Address
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Address Line | 24414 24TH AVE S
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City | DES MOINES
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State | WA
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Zip | 98198-4052
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Country | US
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Telephone | 206-643-1510
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MC60817894
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License Number State | WA
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