Provider Demographics
NPI:1750868618
Name:BRODERICK, VIRGINIA LEE
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LEE
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:LEE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1200 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2179
Mailing Address - Country:US
Mailing Address - Phone:517-315-7522
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-315-7522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010811031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801081103OtherMICHIGAN SOCIAL WORK LICENSE