Provider Demographics
NPI:1659055325
Name:BRODBECK, TAYLOR DANIELLE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:DANIELLE
Last Name:BRODBECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:PENTWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49449-0189
Mailing Address - Country:US
Mailing Address - Phone:517-745-2801
Mailing Address - Fax:
Practice Address - Street 1:388 6TH ST
Practice Address - Street 2:
Practice Address - City:PENTWATER
Practice Address - State:MI
Practice Address - Zip Code:49449-9501
Practice Address - Country:US
Practice Address - Phone:517-745-3367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851115289104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker