Provider Demographics
NPI:1710530209
Name:BRODERICK, NICOLE ELIZABETH (LMHC)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 JANET RD APT 6
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 JANET RD APT 6
Practice Address - Street 2:
Practice Address - City:SOUTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02375-1673
Practice Address - Country:US
Practice Address - Phone:508-443-6692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12928-MH-CC101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health