Provider Demographics
NPI:1013790484
Name:BRODERICK, SOPHIA (LPCC)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E REDLANDS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4724
Mailing Address - Country:US
Mailing Address - Phone:855-984-1788
Mailing Address - Fax:
Practice Address - Street 1:101 E REDLANDS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4724
Practice Address - Country:US
Practice Address - Phone:855-984-1788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14480101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional