Provider Demographics
NPI:1619554623
Name:SONYA BROADUS, LPC PC
Entity Type:Organization
Organization Name:SONYA BROADUS, LPC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KACY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-800-1166
Mailing Address - Street 1:10654 US HIGHWAY 31 STE B
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36527-8691
Mailing Address - Country:US
Mailing Address - Phone:251-800-1166
Mailing Address - Fax:251-308-1591
Practice Address - Street 1:10654 US HIGHWAY 31 STE B
Practice Address - Street 2:
Practice Address - City:SPANISH FORT
Practice Address - State:AL
Practice Address - Zip Code:36527-8691
Practice Address - Country:US
Practice Address - Phone:251-800-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL3403OtherLICENSE