1679946818 NPI number — ANDREA BROADWATER LMHC, CMHS, MHP, LPC

Table of content: ANDREA BROADWATER LMHC, CMHS, MHP, LPC (NPI 1679946818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679946818 NPI number — ANDREA BROADWATER LMHC, CMHS, MHP, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROADWATER
Provider First Name:
ANDREA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC, CMHS, MHP, LPC
Provider Gender Code:
X

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PINTO
Provider Other First Name:
ANDREA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679946818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4518 CASHMERE DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98516-1356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-210-0308
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2232 S MAIN ST # 384
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48103-6938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-210-0308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MC60393707 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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