Provider Demographics
NPI:1194017095
Name:BRODNIK, PATRICK PAUL (MA, MS, PHD(C), LMHC)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:PAUL
Last Name:BRODNIK
Suffix:
Gender:M
Credentials:MA, MS, PHD(C), LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 730053
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32173-0053
Mailing Address - Country:US
Mailing Address - Phone:386-290-8296
Mailing Address - Fax:
Practice Address - Street 1:555 W GRANADA BLVD
Practice Address - Street 2:SUITE B-12
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9485
Practice Address - Country:US
Practice Address - Phone:386-290-8296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10630101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health