Provider Demographics
NPI:1114416955
Name:BROADDUS, DANA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:MARIE
Last Name:BROADDUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:MARIE
Other - Last Name:DIRKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:1810 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:HIGGINSVILLE
Practice Address - State:MO
Practice Address - Zip Code:64037-1537
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210320681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical