Provider Demographics
NPI:1740300078
Name:BROADWELL, SUSAN E (MAPSYD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:MAPSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11505 36TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2304
Mailing Address - Country:US
Mailing Address - Phone:763-509-3885
Mailing Address - Fax:763-559-0149
Practice Address - Street 1:11505 36TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2304
Practice Address - Country:US
Practice Address - Phone:763-509-3885
Practice Address - Fax:763-559-0149
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist