Provider Demographics
NPI:1174804090
Name:BRODERICK, PATTIE S (LISW, CP/AP)
Entity type:Individual
Prefix:
First Name:PATTIE
Middle Name:S
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LISW, CP/AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4017
Mailing Address - Country:US
Mailing Address - Phone:864-241-8222
Mailing Address - Fax:864-241-8222
Practice Address - Street 1:111 MILLS AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4017
Practice Address - Country:US
Practice Address - Phone:864-241-8222
Practice Address - Fax:864-241-8222
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical