Provider Demographics
NPI:1598812034
Name:BROADWATER, CYNDI S (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CYNDI
Middle Name:S
Last Name:BROADWATER
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NC
Mailing Address - Zip Code:27557-0249
Mailing Address - Country:US
Mailing Address - Phone:252-235-2161
Mailing Address - Fax:252-235-2625
Practice Address - Street 1:7907 BUCK DEANS ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLESEX
Practice Address - State:NC
Practice Address - Zip Code:27557
Practice Address - Country:US
Practice Address - Phone:252-235-2161
Practice Address - Fax:252-235-2625
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCOO44981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002806Medicaid