Provider Demographics
NPI:1417411018
Name:BROADNAX, KIM (LISW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 SCARLET OAK DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-3049
Mailing Address - Country:US
Mailing Address - Phone:216-536-3134
Mailing Address - Fax:
Practice Address - Street 1:925 KEYNOTE CIR STE 300
Practice Address - Street 2:
Practice Address - City:BROOKLYN HTS
Practice Address - State:OH
Practice Address - Zip Code:44131-1869
Practice Address - Country:US
Practice Address - Phone:216-931-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.00058321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1972553063OtherNPI
OH9072202Medicaid