Provider Demographics
NPI:1689390981
Name:FANSHAW, BRODY THOMAS (MS, LPC)
Entity type:Individual
Prefix:MR
First Name:BRODY
Middle Name:THOMAS
Last Name:FANSHAW
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6408 BRIDGE RD APT 245
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1832
Mailing Address - Country:US
Mailing Address - Phone:608-285-2911
Mailing Address - Fax:
Practice Address - Street 1:121 S BRISTOL ST STE 102
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-2995
Practice Address - Country:US
Practice Address - Phone:608-285-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7151-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health