Provider Demographics
NPI:1003579483
Name:LAURA A BRODIE PHD CLINICAL & FORENSIC PSYCHOLOGY INC
Entity Type:Organization
Organization Name:LAURA A BRODIE PHD CLINICAL & FORENSIC PSYCHOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-966-5652
Mailing Address - Street 1:296 BEAUVOIR RD STE 360
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1822 15TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2104
Practice Address - Country:US
Practice Address - Phone:228-678-1042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-21
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty