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500 Westgate Dr # 1006 Brockton MA 02301-1855 | |
| (508) 690-6069 | |
| (857) 219-5242 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 500 Westgate Dr # 1006, Brockton, Massachusetts |
| Authorized Official Name and Position | Aisha King (OPERATIONS MANAGER) |
| Authorized Official Contact | 8575260487 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
500 Westgate Dr # 1006 Brockton MA 02301-1855 Ph: (508) 690-6069 | 500 Westgate Dr # 1006 Brockton MA 02301-1855 Ph: (508) 690-6069 |
| NPI Number | 1225688708 |
|---|---|
| Provider Enumeration Date | 09/16/2019 |
| Last Update Date | 05/18/2022 |
| Certification Date | 05/18/2022 |
| Medicare PECOS PAC ID | 5193104107 |
|---|---|
| Medicare Enrollment ID | O20220622002137 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1225688708 | NPI | - | NPPES |
| Provider Name | Kelly Anne Broderick |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1407193758 PECOS PAC ID: 1153700166 Enrollment ID: I20220622002273 |
| Provider Name | Terri Denise Miller |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1295492635 PECOS PAC ID: 2466823315 Enrollment ID: I20230201000304 |
| Provider Name | Nikia Lynn Hackett |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1952884603 PECOS PAC ID: 4880054204 Enrollment ID: I20230718000497 |
| Provider Name | Guan Q Ellerbe |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1578993028 PECOS PAC ID: 6002295011 Enrollment ID: I20240814002834 |
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