Provider Demographics
NPI:1184866741
Name:BRODY, PETER ROBERT
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ROBERT
Last Name:BRODY
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:ROBERT
Other - Last Name:BRODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:312 S CEDROS AVE
Mailing Address - Street 2:#309
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1979
Mailing Address - Country:US
Mailing Address - Phone:858-755-1022
Mailing Address - Fax:
Practice Address - Street 1:312 S CEDROS AVE
Practice Address - Street 2:#309
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1979
Practice Address - Country:US
Practice Address - Phone:858-755-1022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-29
Last Update Date:2009-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5232103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical