Provider Demographics
NPI:1306364534
Name:BRODHEAD, SHONNA JOLENE (LMSW)
Entity Type:Individual
Prefix:
First Name:SHONNA
Middle Name:JOLENE
Last Name:BRODHEAD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7266 BUCKLEY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-2649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BRIGHTPATH COUNSELING
Practice Address - Street 2:7266 BUCKLEY ROAD
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212
Practice Address - Country:US
Practice Address - Phone:315-458-0919
Practice Address - Fax:315-458-0594
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY091721-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY091721-1OtherSTATE LICENSE