Provider Demographics
NPI:1891164109
Name:BROAD, AMANDA (MSW, LSW, ASW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BROAD
Suffix:
Gender:F
Credentials:MSW, LSW, ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 BEARD RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3423
Mailing Address - Country:US
Mailing Address - Phone:707-287-3416
Mailing Address - Fax:
Practice Address - Street 1:3260 BEARD RD
Practice Address - Street 2:SUITE 4
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3423
Practice Address - Country:US
Practice Address - Phone:707-287-3416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW665261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical