Provider Demographics
NPI:1477010395
Name:BRODERICK, TRACY ANN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:BRODERICK
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 1:24460 LYONS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2347
Mailing Address - Country:US
Mailing Address - Phone:661-253-9400
Mailing Address - Fax:661-253-9403
Practice Address - Street 1:24460 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2347
Practice Address - Country:US
Practice Address - Phone:661-253-9400
Practice Address - Fax:661-253-9403
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386100907Medicaid