Active NPI
Debra Lynn Broderick, CDCA
- Addiction (Substance Use Disorder) Counselor
- Logan, OH
National Provider Identifier
1134613243
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Addiction (Substance Use Disorder) Counselor
- License
- 164844
- Practice address
- 30663 Red Rock CT # 1
Logan, OH 43138-9672 - Phone
- (740) 888-1377
- Fax
- (740) 879-2970
- NPI assigned
- Jun 21, 2018
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | 164844 | OH | Primary |
Addresses
Primary practice location
30663 Red Rock CT # 1
Logan, OH 43138-9672
Mailing address
30663 Red Rock CT # 1
Logan, OH 43138-9672
Phone (740) 888-1377
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0096642 | Medicaid | OH |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 164844 | OH | MD | Addiction (Substance Use Disorder) Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1529539200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1529539200000",
"number": "1134613243",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "30663 RED ROCK CT # 1",
"city": "LOGAN",
"state": "OH",
"postal_code": "431389672",
"telephone_number": "740-888-1377",
"fax_number": "740-879-2970"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "30663 RED ROCK CT # 1",
"city": "LOGAN",
"state": "OH",
"postal_code": "431389672",
"telephone_number": "740-888-1377",
"fax_number": "740-879-2970"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BRODERICK",
"first_name": "DEBRA",
"middle_name": "LYNN",
"credential": "CDCA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2018-06-21",
"last_updated": "2018-06-21",
"status": "A"
},
"taxonomies": [
{
"code": "101YA0400X",
"taxonomy_group": "",
"desc": "Counselor, Addiction (Substance Use Disorder)",
"state": "OH",
"license": "164844",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0096642",
"state": "OH"
}
],
"endpoints": [],
"other_names": []
}Other providers in Logan, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 21, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.