Provider Demographics
NPI:1790875409
Name:BRODSLY, SUZANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:BRODSLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 BAY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-3777
Mailing Address - Country:US
Mailing Address - Phone:562-595-0577
Mailing Address - Fax:
Practice Address - Street 1:16480 HARBOR BLVD STE 103
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1361
Practice Address - Country:US
Practice Address - Phone:714-418-9606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS189021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical