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NPI Code Detail

MEDICARE: SUSAN E BROADWELL MA.PSY.D.

MEDICARE: SUSAN E BROADWELL MA.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
1103T00000XPsychologist

General Provider Information

NPI Number : 1740300078
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN E BROADWELL MA.PSY.D.
Provider Business Mailing Address
First Line : 11505 36TH AVE N
Second Line :
City : PLYMOUTH
State : MN
Zip : 55441-2304
Country : US
Telephone Number : 763-509-3885
Fax Number : 763-559-0149
Provider Business Practice Location Address
First Line : 11505 36TH AVE N
Second Line :
City : PLYMOUTH
State : MN
Zip : 55441-2304
Country : US
Telephone Number : 763-509-3885
Fax Number : 763-559-0149
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/30/2007
Last Update Date : 07/08/2007

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