Provider Demographics
NPI:1336545656
Name:BRODIE, MATT (ATC)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:BRODIE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5381 BURR OAK RD
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-2107
Mailing Address - Country:US
Mailing Address - Phone:618-806-4264
Mailing Address - Fax:
Practice Address - Street 1:5381 BURR OAK RD
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-2107
Practice Address - Country:US
Practice Address - Phone:618-806-4264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096003519246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other