Provider Demographics
NPI:1740434893
Name:BRODACK, MARILY ELIZABETH (LMSW)
Entity type:Individual
Prefix:MS
First Name:MARILY
Middle Name:ELIZABETH
Last Name:BRODACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 ILLONA LN
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-5428
Mailing Address - Country:US
Mailing Address - Phone:516-850-0710
Mailing Address - Fax:
Practice Address - Street 1:2041 ILLONA LN
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-5428
Practice Address - Country:US
Practice Address - Phone:516-850-0710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068185-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker