Provider Demographics
NPI:1295253805
Name:BROADUS INTERNATIONAL GROUP NETWORK, LLC
Entity type:Organization
Organization Name:BROADUS INTERNATIONAL GROUP NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:KATESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-447-2505
Mailing Address - Street 1:110 COLISEUM XING # 5050
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5971
Mailing Address - Country:US
Mailing Address - Phone:757-778-9800
Mailing Address - Fax:757-778-9899
Practice Address - Street 1:110 COLISEUM CROSSING
Practice Address - Street 2:#5050
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5971
Practice Address - Country:US
Practice Address - Phone:757-785-4424
Practice Address - Fax:757-785-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP1600X, 101YP2500X, 103K00000X, 104100000X, 106E00000X, 106H00000X, 106S00000X, 251B00000X
VAS6963161251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty