Provider Demographics
NPI:1801177357
Name:BRODLIE, SUSAN (MSRD, CNSC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BRODLIE
Suffix:
Gender:F
Credentials:MSRD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 BROADWAY
Mailing Address - Street 2:RM 703B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1559
Mailing Address - Country:US
Mailing Address - Phone:212-305-6225
Mailing Address - Fax:212-342-4779
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:RM 703B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-305-6225
Practice Address - Fax:212-342-4779
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003807-1133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric