Provider Demographics
NPI:1447787635
Name:BRODERICK, KALYANI GLASS (MS)
Entity Type:Individual
Prefix:
First Name:KALYANI
Middle Name:GLASS
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KALYANI
Other - Middle Name:
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3333 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-1436
Mailing Address - Country:US
Mailing Address - Phone:717-233-1681
Mailing Address - Fax:
Practice Address - Street 1:3333 N FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-1436
Practice Address - Country:US
Practice Address - Phone:717-233-1681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC014468101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional