Provider Demographics
NPI:1619289113
Name:BRODERICK, BENJAMIN M (BGS)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:M
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:BGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3750
Mailing Address - Country:US
Mailing Address - Phone:508-770-0511
Mailing Address - Fax:508-770-0875
Practice Address - Street 1:172 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3750
Practice Address - Country:US
Practice Address - Phone:508-770-0511
Practice Address - Fax:508-770-0875
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor