Provider Demographics
NPI:1073663183
Name:BRODERICK, JAMES L (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:BRODERICK
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 1:1206 CALLE GATO
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101
Mailing Address - Country:US
Mailing Address - Phone:805-898-1276
Mailing Address - Fax:805-708-3020
Practice Address - Street 1:735 STATE ST STE 203
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-5502
Practice Address - Country:US
Practice Address - Phone:805-708-3020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5668103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist