Individual
MR. KELLY G BRODERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
245 FOUNTAIN CT STE 316, LEXINGTON, KY 40509-1888
(859) 257-9210
Mailing address
245 FOUNTAIN CT STE 225, LEXINGTON, KY 40509-1888
(859) 323-6021
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
6364
KY
1041C0700X
Clinical Social Worker
Primary
3992
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1790731081
—
KY
Enumeration date
09/14/2012
Last updated
05/09/2019
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