Provider Demographics
NPI:1356077101
Name:BROACH, SHELBIE
Entity type:Individual
Prefix:
First Name:SHELBIE
Middle Name:
Last Name:BROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 SIOUX CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-9264
Mailing Address - Country:US
Mailing Address - Phone:843-729-9820
Mailing Address - Fax:
Practice Address - Street 1:1420 EBENEZER RD STE 101
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2774
Practice Address - Country:US
Practice Address - Phone:803-619-9055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
SC8270101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty