Provider Demographics
NPI:1376528075
Name:BRODY, STEPHANIE ROBIN (PSYD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROBIN
Last Name:BRODY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MERIAM ST
Mailing Address - Street 2:SUITE #22
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-5300
Mailing Address - Country:US
Mailing Address - Phone:781-861-9813
Mailing Address - Fax:781-861-3274
Practice Address - Street 1:9 MERIAM ST
Practice Address - Street 2:SUITE #22
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-5300
Practice Address - Country:US
Practice Address - Phone:781-861-9813
Practice Address - Fax:781-861-3274
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3998103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABRW03956Medicare ID - Type Unspecified