Provider Demographics
NPI:1518956259
Name:BRODIE, DEBRA ANN (PHD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN
Last Name:BRODIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RIVER PLACE DR STE 5350-G
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4457
Mailing Address - Country:US
Mailing Address - Phone:313-871-1450
Mailing Address - Fax:313-468-1105
Practice Address - Street 1:300 RIVER PLACE DR STE 5350-G
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4457
Practice Address - Country:US
Practice Address - Phone:313-871-1450
Practice Address - Fax:313-468-1105
Is Sole Proprietor?:No
Enumeration Date:2005-10-16
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006340103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-3347895OtherBLUE CROSS BLUE SHIELD
MI037492OtherDMC-CARE
MI38-3347895OtherVALUEOPTIONS