Provider Demographics
NPI:1871660167
Name:BRODIE, VIRGINIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:
Last Name:BRODIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:GINGER
Other - Middle Name:
Other - Last Name:BRODIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:11 E WOODCREST AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052-3342
Mailing Address - Country:US
Mailing Address - Phone:856-662-3681
Mailing Address - Fax:856-662-3681
Practice Address - Street 1:54 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MAPLE SHADE
Practice Address - State:NJ
Practice Address - Zip Code:08052-2432
Practice Address - Country:US
Practice Address - Phone:856-667-5353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC006010001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ038122Medicare ID - Type UnspecifiedMEDICARE NUMBER