MEDICARE: LILLIAN BROADWAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	26-527428

General Provider Information

NPI Number	:	1336076132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLIAN BROADWAY

Provider Business Mailing Address
First Line	:	128 MEMORIAL DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6328
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	128 MEMORIAL DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6328
Country	:	US
Telephone Number	:	888-392-8642
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2026
Last Update Date	:	05/06/2026

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Directions to “ LILLIAN BROADWAY ” Practice Location

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