Provider Demographics
NPI:1861238768
Name:BROADNAX, LASHALLE (LSW)
Entity type:Individual
Prefix:
First Name:LASHALLE
Middle Name:
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8092 CAPTAIN DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8705
Mailing Address - Country:US
Mailing Address - Phone:317-339-7198
Mailing Address - Fax:
Practice Address - Street 1:6655 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8923
Practice Address - Country:US
Practice Address - Phone:888-714-1927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33012144A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker