Provider Demographics
NPI:1437262409
Name:BRODERICK, STACI HUSKA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:HUSKA
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MRS
Other - First Name:STACI
Other - Middle Name:HUSKA
Other - Last Name:BRODERICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:7022 SARDIS RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-6058
Mailing Address - Country:US
Mailing Address - Phone:704-292-4712
Mailing Address - Fax:
Practice Address - Street 1:7022 SARDIS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-6058
Practice Address - Country:US
Practice Address - Phone:704-292-4712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8342235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7413101Medicaid