Provider Demographics
NPI:1407193758
Name:BRODERICK, KELLY ANNE (LICSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 POLO RD APT 235
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-4425
Mailing Address - Country:US
Mailing Address - Phone:207-671-3599
Mailing Address - Fax:
Practice Address - Street 1:152 LYNNWAY STE 2C
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-3420
Practice Address - Country:US
Practice Address - Phone:617-982-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MA1226571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator