Provider Demographics
NPI:1639990229
Name:BROFFMAN, ANDI DORA
Entity type:Individual
Prefix:
First Name:ANDI
Middle Name:DORA
Last Name:BROFFMAN
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 1:103 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1610
Mailing Address - Country:US
Mailing Address - Phone:716-868-7191
Mailing Address - Fax:
Practice Address - Street 1:16 CINEMA DRIVE, SUITE 119
Practice Address - Street 2:SUITE 119
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-793-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP131763104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker