Provider Demographics
NPI:1922201797
Name:BROADWAY, PENNY JO
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:JO
Last Name:BROADWAY
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 1:45351 11TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-1706
Mailing Address - Country:US
Mailing Address - Phone:661-726-1978
Mailing Address - Fax:
Practice Address - Street 1:1529 E PALMDALE BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-2034
Practice Address - Country:US
Practice Address - Phone:661-272-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007301AMedicaid