Provider Demographics
NPI:1912155144
Name:BROEDER, BRAD STEPHEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:STEPHEN
Last Name:BROEDER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1266 FIRST STREET, SUITE #11
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-5519
Mailing Address - Country:US
Mailing Address - Phone:941-953-6804
Mailing Address - Fax:941-953-3704
Practice Address - Street 1:1266 FIRST STREET, SUITE #11
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-5519
Practice Address - Country:US
Practice Address - Phone:941-953-6804
Practice Address - Fax:941-953-3704
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY-5583103TA0700X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic