Provider Demographics
NPI:1801254297
Name:BRODIE, VANESSA (PSYD)
Entity type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:
Last Name:BRODIE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4509
Mailing Address - Country:US
Mailing Address - Phone:862-277-0227
Mailing Address - Fax:
Practice Address - Street 1:395 W AVON RD STE 1
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001
Practice Address - Country:US
Practice Address - Phone:862-277-0227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00537700103T00000X
NY021358-1103T00000X
CT3855103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist