Provider Demographics
NPI:1881817443
Name:BRODERICK, KELLY R (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:R
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2812
Mailing Address - Country:US
Mailing Address - Phone:708-352-1880
Mailing Address - Fax:708-352-1880
Practice Address - Street 1:515 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2812
Practice Address - Country:US
Practice Address - Phone:708-352-1880
Practice Address - Fax:708-352-1880
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist