Provider Demographics
NPI:1750907879
Name:BROADWAY PSYCHIATRY LLC
Entity type:Organization
Organization Name:BROADWAY PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VELILE
Authorized Official - Middle Name:SIBUSISIWE
Authorized Official - Last Name:NKOLOMI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:469-733-2090
Mailing Address - Street 1:2657 JOHNSON CT
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-1696
Mailing Address - Country:US
Mailing Address - Phone:469-733-2090
Mailing Address - Fax:
Practice Address - Street 1:3960 BROADWAY BLVD STE 232
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-2591
Practice Address - Country:US
Practice Address - Phone:469-733-2090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-24
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty