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General NPI Number Information
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NPI Number | 1205407970
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Entity Type | Individual
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Provider Name | WILLOW NICOLE BROADDUS LCMHC, LPC, MA
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Gender | Female
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Dates
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Enumeration Date | 07/05/2021
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Last Update Date | 04/12/2024
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Provider Practice Location Address
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Address Line | 138 OLD STAGE RD
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City | GRANVILLE
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State | VT
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Zip | 05747-9675
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Country | US
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Telephone | 802-565-7124
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 165
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City | HANCOCK
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State | VT
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Zip | 05748-0165
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Country | US
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Telephone | 802-565-7124
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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 | 068.0134330
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License Number State | VT
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