Provider Demographics
NPI:1013417195
Name:BROADNAX, KENYA MARIE
Entity Type:Individual
Prefix:MS
First Name:KENYA
Middle Name:MARIE
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KENYA
Other - Middle Name:M
Other - Last Name:BROADNAX-BYNUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24414 24TH AVE S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-4052
Mailing Address - Country:US
Mailing Address - Phone:206-643-1510
Mailing Address - Fax:
Practice Address - Street 1:1033 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1845
Practice Address - Country:US
Practice Address - Phone:206-242-1126
Practice Address - Fax:206-829-1258
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60817894101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health