Provider Demographics
NPI:1780072512
Name:BARRY BRODY PHD LLC
Entity type:Organization
Organization Name:BARRY BRODY PHD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER-MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:386-755-1720
Mailing Address - Street 1:871 SW STATE ROAD 47
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0433
Mailing Address - Country:US
Mailing Address - Phone:386-755-1720
Mailing Address - Fax:386-754-1325
Practice Address - Street 1:871 SW STATE ROAD 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0433
Practice Address - Country:US
Practice Address - Phone:386-755-1720
Practice Address - Fax:386-754-1325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-01
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
FLMT983261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)