Provider Demographics
NPI:1245743509
Name:BROADEN, DESTINY (AUD)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:BROADEN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 NUEVO LEON ST UNIT 7
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-4100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98 E LAKE MEAD PKWY STE 105
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-6443
Practice Address - Country:US
Practice Address - Phone:702-861-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA2181231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist