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NPI Code Detail

MEDICARE: KIM BROADNAX LISW

MEDICARE: KIM BROADNAX LISW
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
11041C0700XClinical Social WorkerI.0005832OH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11972553063OTHEROHNPI
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1417411018
Entity Type Code : Individual
Provider Name (Legal Business Name) : KIM BROADNAX LISW
Provider Business Mailing Address
First Line : 5905 SCARLET OAK DR
Second Line :
City : BEDFORD HTS
State : OH
Zip : 44146-3049
Country : US
Telephone Number : 216-536-3134
Fax Number :
Provider Business Practice Location Address
First Line : 925 KEYNOTE CIR STE 300
Second Line :
City : BROOKLYN HTS
State : OH
Zip : 44131-1869
Country : US
Telephone Number : 216-931-1400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/28/2019
Last Update Date : 01/28/2019

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Directions to “ KIM BROADNAX LISW” Practice Location

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