Provider Demographics
NPI:1376638775
Name:BRODY, BARRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:
Last Name:BRODY
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 1:871 SW STATE ROAD 47
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0433
Mailing Address - Country:US
Mailing Address - Phone:386-755-1720
Mailing Address - Fax:386-754-1325
Practice Address - Street 1:871 SW STATE ROAD 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0433
Practice Address - Country:US
Practice Address - Phone:386-755-1720
Practice Address - Fax:386-754-1325
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0000983106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist