Provider Demographics
NPI:1043342496
Name:BROADWAY, MARC S (BA, SAA)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:S
Last Name:BROADWAY
Suffix:
Gender:M
Credentials:BA, SAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 TROY KING RD TRLR 10
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-3123
Mailing Address - Country:US
Mailing Address - Phone:505-566-0336
Mailing Address - Fax:
Practice Address - Street 1:2011 TROY KING RD TRLR 10
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-3123
Practice Address - Country:US
Practice Address - Phone:505-566-0336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4455101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)