Provider Demographics
NPI:1902001373
Name:BRODEN, RENAE A (LICSW)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:A
Last Name:BRODEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 CIRCLE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7956
Mailing Address - Country:US
Mailing Address - Phone:701-772-5145
Mailing Address - Fax:
Practice Address - Street 1:1616 S 17TH ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5355
Practice Address - Country:US
Practice Address - Phone:701-795-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25918OtherNDBCBS PROVIDER NUMBER
ND25918OtherNDBCBS PROVIDER NUMBER