Provider Demographics
NPI:1851747976
Name:BROADY, KELLY (MS, CGC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BROADY
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 QUEBEC AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-2509
Mailing Address - Country:US
Mailing Address - Phone:612-460-8791
Mailing Address - Fax:
Practice Address - Street 1:123 W 18TH ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4127
Practice Address - Country:US
Practice Address - Phone:612-460-8791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-07
Last Update Date:2016-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC000753170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS