Provider Demographics
NPI:1205407970
Name:BROADDUS, WILLOW NICOLE (LCMHC, LPC, MA)
Entity type:Individual
Prefix:MRS
First Name:WILLOW
Middle Name:NICOLE
Last Name:BROADDUS
Suffix:
Gender:F
Credentials:LCMHC, LPC, MA
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 165
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:VT
Mailing Address - Zip Code:05748-0165
Mailing Address - Country:US
Mailing Address - Phone:802-565-7124
Mailing Address - Fax:
Practice Address - Street 1:138 OLD STAGE RD
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:VT
Practice Address - Zip Code:05747-9675
Practice Address - Country:US
Practice Address - Phone:802-565-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-05
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0134330101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health