Provider Demographics
NPI:1598166993
Name:BROADUS, KATESHA SHANEE (LCSW, BC-TMH)
Entity Type:Individual
Prefix:MRS
First Name:KATESHA
Middle Name:SHANEE
Last Name:BROADUS
Suffix:
Gender:F
Credentials:LCSW, BC-TMH
Other - Prefix:MS
Other - First Name:KATESHA
Other - Middle Name:SHANEE
Other - Last Name:CROMWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 COLISEUM CROSSING
Mailing Address - Street 2:#5050
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5971
Mailing Address - Country:US
Mailing Address - Phone:757-785-4424
Mailing Address - Fax:
Practice Address - Street 1:110 COLISEUM CROSSING #5050
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666
Practice Address - Country:US
Practice Address - Phone:757-785-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0090611041C0700X
VA09040101491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical