Healthcare Provider Details

I. General information

NPI: 1275464968
Provider Name (Legal Business Name): BRODERICK SRODES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 W SABAL PALM PL STE 200
LONGWOOD FL
32779-3621
US

IV. Provider business mailing address

607 HERMITS TRL
ALTAMONTE SPRINGS FL
32701-2703
US

V. Phone/Fax

Practice location:
  • Phone: 407-676-4118
  • Fax:
Mailing address:
  • Phone: 941-915-0047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH29289
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: