Provider Demographics
NPI:1851672075
Name:BROADNAX, AMELIA LILLIAN
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:LILLIAN
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4385 ROSEBUD LN
Mailing Address - Street 2:APT G
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6247
Mailing Address - Country:US
Mailing Address - Phone:619-654-7326
Mailing Address - Fax:
Practice Address - Street 1:1250 6TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-4300
Practice Address - Country:US
Practice Address - Phone:619-810-8603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)