Provider Demographics
NPI:1649416033
Name:BROADNAX, DIANE DILLARD (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:DILLARD
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13256 MANOR TER
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-3952
Mailing Address - Country:US
Mailing Address - Phone:301-829-3371
Mailing Address - Fax:301-829-3391
Practice Address - Street 1:2570 SHERMAN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-2299
Practice Address - Country:US
Practice Address - Phone:202-232-6100
Practice Address - Fax:202-483-4560
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3015331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical