Provider Demographics
NPI:1508285628
Name:BROADNAX, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BROADNAX
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 1:500 FAIRWAY DR. STE, 102
Mailing Address - Street 2:BUTTERFLY EFFECTS LLC
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441
Mailing Address - Country:US
Mailing Address - Phone:888-880-9270
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRWAY DR.
Practice Address - Street 2:102, BUTTERFLY EFFECTS LLC
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist