Provider Demographics
NPI:1497184121
Name:BROADWELL, SHERRY DIANE (PHD)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:DIANE
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-0012
Mailing Address - Country:US
Mailing Address - Phone:706-949-3131
Mailing Address - Fax:
Practice Address - Street 1:517B GREEN STREET
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:706-949-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist