Provider Demographics
NPI:1447803150
Name:BRODERICK, COURTNEY NICOLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:NICOLE
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 N GENERALS BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-3537
Mailing Address - Country:US
Mailing Address - Phone:704-748-0616
Mailing Address - Fax:
Practice Address - Street 1:518 N GENERALS BLVD STE D
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-3537
Practice Address - Country:US
Practice Address - Phone:704-748-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13681235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14171686OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION