Healthcare Provider Details

I. General information

NPI: 1225375165
Provider Name (Legal Business Name): MICHAEL DAVID BRODEUR PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 NE WILSON RD
PULLMAN WA
99164-0001
US

IV. Provider business mailing address

825 PALOUSE VW
PULLMAN WA
99163-5261
US

V. Phone/Fax

Practice location:
  • Phone: 509-335-4511
  • Fax:
Mailing address:
  • Phone: 401-447-0459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60297192
License Number StateWA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: