Basic Information
| Provider Information | |||||||||
| NPI: | 1114191582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROADWAY | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | PRING | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC, LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1104A S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272923134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362422450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 9 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 705 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.