Provider Demographics
NPI:1205976982
Name:BRODERICK, SHERRY L (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SHERRY
Middle Name:L
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 2ND ST. SE
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701
Mailing Address - Country:US
Mailing Address - Phone:701-852-2498
Mailing Address - Fax:
Practice Address - Street 1:215 2ND ST SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3924
Practice Address - Country:US
Practice Address - Phone:701-857-4410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND517235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND517OtherND STATE LICENSE NUMBER
ND58531Medicaid