Provider Demographics
NPI:1265616973
Name:BROADDUS, DARRELL L (PHD)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:L
Last Name:BROADDUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6461 ASPEN GARDENS WAY
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-5626
Mailing Address - Country:US
Mailing Address - Phone:916-705-7388
Mailing Address - Fax:
Practice Address - Street 1:8029 LA MESA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-6434
Practice Address - Country:US
Practice Address - Phone:619-668-0600
Practice Address - Fax:619-466-2662
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 20101103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical