Provider Demographics
NPI:1689436644
Name:BRODERICK, VANESSA (LMSW)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W CHANDLER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6100
Mailing Address - Country:US
Mailing Address - Phone:812-569-2516
Mailing Address - Fax:
Practice Address - Street 1:1600 W CHANDLER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6100
Practice Address - Country:US
Practice Address - Phone:812-569-2516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-21473104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker