Provider Demographics
NPI:1093949919
Name:BROD, EMILY KRISTIN (LCSW)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:KRISTIN
Last Name:BROD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 NOYES ST
Mailing Address - Street 2:APT. A
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4442
Mailing Address - Country:US
Mailing Address - Phone:207-712-4905
Mailing Address - Fax:
Practice Address - Street 1:25 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4869
Practice Address - Country:US
Practice Address - Phone:207-712-0146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC117271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical