Basic Information
| Provider Information | |||||||||
| NPI: | 1053645119 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROADWELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 KUNEHI ST | ||||||||
| Address2: | APT 206 | ||||||||
| City: | KAPOLEI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967072069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086746641 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2501 W 22ND ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053363230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.