Provider Demographics
NPI:1821393182
Name:BROADBENT, KYLE DAVID
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:DAVID
Last Name:BROADBENT
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 1:6501 W DESCHUTES AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7772
Mailing Address - Country:US
Mailing Address - Phone:509-939-3204
Mailing Address - Fax:
Practice Address - Street 1:6501 W DESCHUTES AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7772
Practice Address - Country:US
Practice Address - Phone:509-939-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63294101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherMEDI-CAL
CA7667OtherMEDI-CAL
CA7368OtherMEDI-CAL