Healthcare Provider Details

I. General information

NPI: 1922093913
Provider Name (Legal Business Name): MARY ALICE BRODBECK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 SHAW AVE
MCKEESPORT PA
15132-2918
US

IV. Provider business mailing address

500 WALNUT ST THIRD FLOOR
MCKEESPORT PA
15132-2801
US

V. Phone/Fax

Practice location:
  • Phone: 412-675-8585
  • Fax: 412-675-8533
Mailing address:
  • Phone: 412-675-8530
  • Fax: 412-675-8533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW01360
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier628556
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: