Provider Demographics
NPI:1427548486
Name:BROADWAY, CHARISA
Entity Type:Individual
Prefix:
First Name:CHARISA
Middle Name:
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11322 SUSANS POINT DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6308
Mailing Address - Country:US
Mailing Address - Phone:352-396-1453
Mailing Address - Fax:
Practice Address - Street 1:17335 PAGONIA DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6011
Practice Address - Country:US
Practice Address - Phone:352-396-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician