Basic Information
| Provider Information | |||||||||
| NPI: | 1659608347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | AMY | ||||||||
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| Credential: | QBHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 COUNTY ROAD 458 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726538212 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 N CARDINAL DR STE 7 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726533274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704255644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2009 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 373H00000X | N | Nursing Service Related Providers | Day Training/Habilitation Specialist | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.