Provider Demographics
NPI:1265327894
Name:BRODERICK, SARAH (EDS, NCSP)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:X
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 NE 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4096
Mailing Address - Country:US
Mailing Address - Phone:503-916-6282
Mailing Address - Fax:
Practice Address - Street 1:7200 NE 11TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-4096
Practice Address - Country:US
Practice Address - Phone:503-916-6282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR523090103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool