Provider Demographics
NPI:1366011983
Name:BRODERSEN, JOANNA R (LPC)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:R
Last Name:BRODERSEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2546 S BRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-3503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 MARKET ST STE 110
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1824
Practice Address - Country:US
Practice Address - Phone:417-221-6655
Practice Address - Fax:635-217-9140
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC8553101YM0800X
MO2021030516101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional