Provider Demographics
NPI:1740215201
Name:BROADFIELD, CHARLES S (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:S
Last Name:BROADFIELD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 CHESAPEAKE BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23513-5325
Mailing Address - Country:US
Mailing Address - Phone:757-853-1409
Mailing Address - Fax:757-853-0825
Practice Address - Street 1:5750 CHESAPEAKE BLVD
Practice Address - Street 2:STE 105
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23513-5325
Practice Address - Country:US
Practice Address - Phone:757-853-1409
Practice Address - Fax:757-853-0825
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANAADAC CERT #013537101YA0400X
VA0717000492106H00000X
VA0701000320101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
170089OtherCOMPSY
VA040416OtherBC/BS
62-91986OtherUNITED BEHAV HEALTH
212164-312164OtherMDIPA
80176OtherSENTARA OPTIMA