NPI Code Detail JSON Logo

1205407970 NPI number — WILLOW NICOLE BROADDUS LCMHC, LPC, MA

NPI Number: 1205407970
Health Care Provider/Practitioner: WILLOW NICOLE BROADDUS LCMHC, LPC, MA

Information about “1205407970” NPI (WILLOW NICOLE BROADDUS LCMHC, LPC, MA) exists in 1205407970 in HTML format HTML  |  1205407970 in plain Text format TXT  |  1205407970 in PDF (Portable Document Format) PDF  |  1205407970 in an XML format XML  formats.

NPI Number : 1205407970 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1205407970",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "BROADDUS",
    "FirstName": "WILLOW",
    "MiddleName": "NICOLE",
    "NamePrefix": "MRS.",
    "NameSuffix": null,
    "Credential": "LCMHC, LPC, MA",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "PO BOX 165",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "HANCOCK",
    "MailingAddressStateName": "VT",
    "MailingAddressPostalCode": "05748-0165",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "802-565-7124",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "138 OLD STAGE RD",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "GRANVILLE",
    "PracticeLocationAddressStateName": "VT",
    "PracticeLocationAddressPostalCode": "05747-9675",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "802-565-7124",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "07/05/2021",
    "LastUpdateDate": "04/12/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "101YM0800X",
        "TaxonomyName": "Mental Health Counselor",
        "LicenseNumber": "068.0134330",
        "LicenseNumberStateCode": "VT",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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