Provider Demographics
NPI:1922479872
Name:BROADBENT, LEXONA (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:LEXONA
Middle Name:
Last Name:BROADBENT
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 ROUTE 21
Mailing Address - Street 2:
Mailing Address - City:SHORTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14548-9502
Mailing Address - Country:US
Mailing Address - Phone:585-289-9649
Mailing Address - Fax:
Practice Address - Street 1:1506 ROUTE 21
Practice Address - Street 2:
Practice Address - City:SHORTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14548-9502
Practice Address - Country:US
Practice Address - Phone:585-289-9649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR075189-11041C0700X
1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool