Provider Demographics
NPI:1245733799
Name:BRODERSON, BRITTANY (LSW)
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:BRODERSON
Suffix:
Gender:F
Credentials:LSW
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 279
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:ND
Mailing Address - Zip Code:58436-0279
Mailing Address - Country:US
Mailing Address - Phone:701-349-3271
Mailing Address - Fax:701-349-3277
Practice Address - Street 1:205 15TH ST N
Practice Address - Street 2:
Practice Address - City:ELLENDALE
Practice Address - State:ND
Practice Address - Zip Code:58436-7600
Practice Address - Country:US
Practice Address - Phone:701-349-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5144104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker