MEDICARE: KELBY BRODDIE LMFT

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	106H00000X	Marriage & Family Therapist	LF61239188	WA

General Provider Information

NPI Number	:	1760032379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELBY BRODDIE LMFT

Provider Business Mailing Address
First Line	:	4350 CORDATA PKWY STE 102
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98226-8278
Country	:	US
Telephone Number	:	360-922-6977
Fax Number	:

Provider Business Practice Location Address
First Line	:	4350 CORDATA PKWY STE 102
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98226-8278
Country	:	US
Telephone Number	:	360-922-6977
Fax Number	:

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

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	07/27/2022

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