Basic Information
| Provider Information | |||||||||
| NPI: | 1831360833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROADWATER | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAUGER | ||||||||
| OtherFirstName: | MELANIE | ||||||||
| OtherMiddleName: | RAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2375 GARDEN WAY | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161485209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249835454 | ||||||||
| FaxNumber: | 7249835428 | ||||||||
| Practice Location | |||||||||
| Address1: | 348 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161252608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245887814 | ||||||||
| FaxNumber: | 7245887986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2008 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PC003668 | PA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.