Provider Demographics
NPI:1457435836
Name:BRODIE, BRUCE ROBERTSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROBERTSON
Last Name:BRODIE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-2335
Mailing Address - Country:US
Mailing Address - Phone:310-261-6181
Mailing Address - Fax:310-829-7868
Practice Address - Street 1:3201 WILSHIRE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-2335
Practice Address - Country:US
Practice Address - Phone:310-261-6181
Practice Address - Fax:310-829-7868
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6574103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical