Provider Demographics
NPI:1245613819
Name:BRODY, BROOKE H (LCSW-C, LCADC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:H
Last Name:BRODY
Suffix:
Gender:M
Credentials:LCSW-C, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621A 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-5123
Mailing Address - Country:US
Mailing Address - Phone:240-994-4926
Mailing Address - Fax:
Practice Address - Street 1:621A 2ND ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5123
Practice Address - Country:US
Practice Address - Phone:240-994-4926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA400101YA0400X
MD123601041C0700X
CALCSW990301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)