Provider Demographics
NPI:1912229436
Name:BROAD, ROBERT DANIEL (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DANIEL
Last Name:BROAD
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 1:141 EAST 55TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWYORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022
Mailing Address - Country:US
Mailing Address - Phone:212-980-8063
Mailing Address - Fax:212-980-8063
Practice Address - Street 1:141 EAST 55TH STREET
Practice Address - Street 2:SUITE1H
Practice Address - City:NEWYORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:212-980-8063
Practice Address - Fax:212-980-8063
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4164103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool