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General NPI Number Information
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NPI Number | 1043342496
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Entity Type | Individual
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Provider Name | MARC S. BROADWAY B.A., SAA
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Gender | Male
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2011 TROY KING RD TRLR 10
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City | FARMINGTON
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State | NM
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Zip | 87401-3123
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Country | US
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Telephone | 505-566-0336
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Fax |
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Provider Business Mailing Address
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Address Line | 2011 TROY KING RD TRLR 10
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City | FARMINGTON
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State | NM
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Zip | 87401-3123
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Country | US
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Telephone | 505-566-0336
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 4455
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License Number State | NM
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