Provider Demographics
NPI:1457921454
Name:WENDICHANSKY BRODSKY, CAROLINE IVETTE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:IVETTE
Last Name:WENDICHANSKY BRODSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81215-0518
Mailing Address - Country:US
Mailing Address - Phone:719-582-3267
Mailing Address - Fax:
Practice Address - Street 1:4720 GALLEY RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-2735
Practice Address - Country:US
Practice Address - Phone:719-422-7691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0106797101YM0800X, 101Y00000X
CO00013891103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist