Provider Demographics
NPI:1750562112
Name:BROADWATER, DENISE ANN (LPC)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:ANN
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-3850
Mailing Address - Country:US
Mailing Address - Phone:864-520-2020
Mailing Address - Fax:864-640-4400
Practice Address - Street 1:105 COMMONS WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-3850
Practice Address - Country:US
Practice Address - Phone:864-520-2020
Practice Address - Fax:864-640-4400
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5164101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC322842 SCMedicaid
SC5164OtherSTATE OF SOUTH CAROLINA
SC5164OtherSTATE OF SOUTH CAROLINA