Provider Demographics
NPI:1124209275
Name:BROADBENT, DENNIS E (PHD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:E
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2432 W. PEORIA AVENUE
Mailing Address - Street 2:SUITE 1327
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029
Mailing Address - Country:US
Mailing Address - Phone:602-866-3432
Mailing Address - Fax:602-866-3764
Practice Address - Street 1:2432 W. PEORIA AVENUE
Practice Address - Street 2:SUITE 1327
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029
Practice Address - Country:US
Practice Address - Phone:602-866-3432
Practice Address - Fax:602-866-3764
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ903103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZPHD903Medicare UPIN