Provider Demographics
NPI:1003031154
Name:BRODER, MICHAEL S (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:BRODER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 LOCUST ST
Mailing Address - Street 2:7G
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4223
Mailing Address - Country:US
Mailing Address - Phone:215-545-7000
Mailing Address - Fax:215-545-7011
Practice Address - Street 1:1420 LOCUST ST
Practice Address - Street 2:7G
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4223
Practice Address - Country:US
Practice Address - Phone:215-545-7000
Practice Address - Fax:215-545-7011
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003069-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist