Provider Demographics
NPI:1932158417
Name:BROD, MARTHALEE T (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTHALEE
Middle Name:T
Last Name:BROD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 HARVARD AVE
Mailing Address - Street 2:BOX 155
Mailing Address - City:MOUNT GRETNA
Mailing Address - State:PA
Mailing Address - Zip Code:17064
Mailing Address - Country:US
Mailing Address - Phone:717-964-1850
Mailing Address - Fax:717-964-1850
Practice Address - Street 1:222 HARVARD AVE
Practice Address - Street 2:BOX 155
Practice Address - City:MOUNT GRETNA
Practice Address - State:PA
Practice Address - Zip Code:17064
Practice Address - Country:US
Practice Address - Phone:717-964-1850
Practice Address - Fax:717-964-1850
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007990L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017546030005Medicaid
PA0017546030005Medicaid