Provider Demographics
NPI:1275975914
Name:BROADHEAD, CARLY (MA, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BROADHEAD
Suffix:
Gender:F
Credentials:MA, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11828 W FAIRVIEW AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-7802
Mailing Address - Country:US
Mailing Address - Phone:986-200-9268
Mailing Address - Fax:
Practice Address - Street 1:3071 E FRANKLIN RD STE 201
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-807-2877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH3237Medicaid