Provider Demographics
NPI:1942421995
Name:BROADWELL, GILDA G (PHD)
Entity Type:Individual
Prefix:DR
First Name:GILDA
Middle Name:G
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2474
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-2474
Mailing Address - Country:US
Mailing Address - Phone:772-692-8585
Mailing Address - Fax:772-692-5651
Practice Address - Street 1:500 NW DIXIE HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-1186
Practice Address - Country:US
Practice Address - Phone:772-692-8585
Practice Address - Fax:772-692-5651
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5591103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54364YMedicare ID - Type Unspecified