Provider Demographics
NPI:1639204423
Name:BRODERICK, DEBRA JEAN (PYSD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:JEAN
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:PYSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 SIMPSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2440
Mailing Address - Country:US
Mailing Address - Phone:651-645-3998
Mailing Address - Fax:
Practice Address - Street 1:357 KELLOGG BLVD E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1411
Practice Address - Country:US
Practice Address - Phone:651-295-1422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4744103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling