Provider Demographics
NPI:1417378837
Name:BRODSKY, MARLA (RD, LD)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:BRODSKY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2027 W GREENLEAF AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-3509
Mailing Address - Country:US
Mailing Address - Phone:773-330-8275
Mailing Address - Fax:
Practice Address - Street 1:2027 W GREENLEAF AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-3509
Practice Address - Country:US
Practice Address - Phone:773-330-8275
Practice Address - Fax:773-973-0030
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001893133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered