Provider Demographics
NPI:1548825771
Name:BROADLEY, RONALD JAMES (CLINICAL SOCIAL WORK)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:JAMES
Last Name:BROADLEY
Suffix:
Gender:M
Credentials:CLINICAL SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 DONNELLY AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1560
Mailing Address - Country:US
Mailing Address - Phone:734-686-2621
Mailing Address - Fax:
Practice Address - Street 1:281 LACLAIR ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2988
Practice Address - Country:US
Practice Address - Phone:541-266-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011037981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical