Provider Demographics
NPI:1629279070
Name:BRODBAR, DORITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:DORITH
Middle Name:
Last Name:BRODBAR
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 1:14 VENETIAN PROMENADE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-6536
Mailing Address - Country:US
Mailing Address - Phone:631-957-4601
Mailing Address - Fax:
Practice Address - Street 1:887 KELLUM ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1508
Practice Address - Country:US
Practice Address - Phone:631-884-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016593103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist