Provider Demographics
NPI:1730714247
Name:BROADSWORD, TINA MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:BROADSWORD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4700
Mailing Address - Fax:208-625-4701
Practice Address - Street 1:14950 N COEUR DALENE ST
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-6484
Practice Address - Country:US
Practice Address - Phone:208-687-0538
Practice Address - Fax:208-687-3185
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW37001104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker