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NPI Code Detail

MEDICARE: MR. DAVID L. BRODERICK JR. B.A.

MEDICARE: MR. DAVID L. BRODERICK JR. B.A.
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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1730372053
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. DAVID L. BRODERICK JR. B.A.
Provider Business Mailing Address
First Line : 3036 FENELON ST
Second Line :
City : SAN DIEGO
State : CA
Zip : 92106-2268
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3036 FENELON ST
Second Line :
City : SAN DIEGO
State : CA
Zip : 92106-2268
Country : US
Telephone Number : 603-540-1756
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/21/2007
Last Update Date : 08/21/2007

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