Provider Demographics
NPI:1467909556
Name:BRODMAN, DOUGLAS M (PHD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:BRODMAN
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 1:577 2ND AVE APT 56
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6349
Mailing Address - Country:US
Mailing Address - Phone:917-599-7743
Mailing Address - Fax:
Practice Address - Street 1:333 E 43RD ST LBBY 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-4819
Practice Address - Country:US
Practice Address - Phone:917-599-7743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021902103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical