Provider Demographics
NPI:1558971549
Name:BROADUS, ALICIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:
Last Name:BROADUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44175 BEAVER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-4198
Mailing Address - Country:US
Mailing Address - Phone:910-257-3278
Mailing Address - Fax:
Practice Address - Street 1:44175 BEAVER CREEK DR
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619-4198
Practice Address - Country:US
Practice Address - Phone:910-257-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0119801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical