Provider Demographics
NPI:1588641989
Name:BRODY, CONSTANCE LOUISE NESBITT (PHD)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE LOUISE
Middle Name:NESBITT
Last Name:BRODY
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 1:462 PARK AVE W
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3118
Mailing Address - Country:US
Mailing Address - Phone:419-529-9944
Mailing Address - Fax:519-529-9989
Practice Address - Street 1:462 PARK AVE W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3118
Practice Address - Country:US
Practice Address - Phone:419-529-9944
Practice Address - Fax:519-529-9989
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4741101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0954810Medicaid
OHCP16963Medicare PIN