Provider Demographics
NPI:1700825007
Name:BRODEUR, EMILY GRIFFIN (LICENSED CLINICAL SO)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:GRIFFIN
Last Name:BRODEUR
Suffix:
Gender:F
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 E IRIS DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-3110
Mailing Address - Country:US
Mailing Address - Phone:615-297-0430
Mailing Address - Fax:615-352-1420
Practice Address - Street 1:524 E IRIS DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204-3110
Practice Address - Country:US
Practice Address - Phone:615-297-0430
Practice Address - Fax:615-352-1420
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000679104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
0171951000OtherMAGELLAN
TN3694828Medicaid
TN4048148OtherBLUE CROSS
3694828Medicare ID - Type Unspecified