Provider Demographics
NPI:1336363647
Name:BROUDY, RISA EVE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RISA
Middle Name:EVE
Last Name:BROUDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5711 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-1003
Mailing Address - Country:US
Mailing Address - Phone:703-351-1036
Mailing Address - Fax:
Practice Address - Street 1:1655 FORT MYER DR STE 820
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22209-3106
Practice Address - Country:US
Practice Address - Phone:703-965-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY1000254103T00000X
VA0810003440103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist