Provider Demographics
NPI:1366635518
Name:BRODERICK, DANIEL JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3528 CHIANTI CIR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-4272
Mailing Address - Country:US
Mailing Address - Phone:765-808-1687
Mailing Address - Fax:
Practice Address - Street 1:3528 CHIANTI CIR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-4272
Practice Address - Country:US
Practice Address - Phone:765-808-1687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
IN20041132A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200532030AMedicaid
IN229550AMedicare PIN
IN200532030AMedicaid