Provider Demographics
NPI:1831360833
Name:BROADWATER, MELANIE RAE (MA)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:RAE
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:RAE
Other - Last Name:HAUGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2375 GARDEN WAY
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-5209
Mailing Address - Country:US
Mailing Address - Phone:724-983-5454
Mailing Address - Fax:724-983-5428
Practice Address - Street 1:348 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-2608
Practice Address - Country:US
Practice Address - Phone:724-588-7814
Practice Address - Fax:724-588-7986
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003668101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional