Provider Demographics
NPI:1659001956
Name:MCELROY, BRODERICK SHUN
Entity Type:Individual
Prefix:
First Name:BRODERICK
Middle Name:SHUN
Last Name:MCELROY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8324 SE RHINE ST APT 12
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2388
Mailing Address - Country:US
Mailing Address - Phone:870-818-6152
Mailing Address - Fax:
Practice Address - Street 1:23839 SW DANIEL RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97078-5400
Practice Address - Country:US
Practice Address - Phone:503-217-2058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist