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NPI Code Detail

MEDICARE: PROF. STACI BROADWELL PSY.D

MEDICARE: PROF. STACI BROADWELL PSY.D
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
1103TC0700XClinical Psychologist017898NY
2103TC0700XClinical Psychologist4519AZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1467696419
Entity Type Code : Individual
Provider Name (Legal Business Name) : PROF. STACI BROADWELL PSY.D
Provider Business Mailing Address
First Line : 2702 N 3RD ST STE 4020
Second Line :
City : PHOENIX
State : AZ
Zip : 85004-4608
Country : US
Telephone Number : 602-323-3492
Fax Number : 602-323-3399
Provider Business Practice Location Address
First Line : 3830 E VAN BUREN ST
Second Line :
City : PHOENIX
State : AZ
Zip : 85008-6920
Country : US
Telephone Number : 602-243-7277
Fax Number : 602-286-0808
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/21/2009
Last Update Date : 06/12/2024

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