Provider Demographics
NPI:1770191801
Name:JOHNSON, BRODDRICK RONZELL (LPC)
Entity Type:Individual
Prefix:
First Name:BRODDRICK
Middle Name:RONZELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 IRIS ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4939
Mailing Address - Country:US
Mailing Address - Phone:985-414-5275
Mailing Address - Fax:
Practice Address - Street 1:102 IRIS ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4939
Practice Address - Country:US
Practice Address - Phone:985-414-5275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator