Provider Demographics
NPI:1922613660
Name:BROADNAX, SHELBY ANNALISA
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:ANNALISA
Last Name:BROADNAX
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 1:400 29TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1029 DONCASTER DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4713
Practice Address - Country:US
Practice Address - Phone:925-864-6583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst