Provider Demographics
NPI:1053645119
Name:BROADWELL, MICHAEL D (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:BROADWELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 40TH AVE NW STE 210
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-1769
Mailing Address - Country:US
Mailing Address - Phone:507-516-0227
Mailing Address - Fax:507-516-0228
Practice Address - Street 1:3535 40TH AVE NW STE 210
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1769
Practice Address - Country:US
Practice Address - Phone:507-516-0227
Practice Address - Fax:507-516-0228
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103K00000X, 103T00000X
MNLP6869103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst