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General NPI Number Information
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NPI Number | 1063611341
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Entity Type | Individual
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Provider Name | LAURA ANNE BRODIE PH.D.
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Gender | Female
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Dates
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Enumeration Date | 07/16/2007
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Last Update Date | 08/18/2021
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Provider Practice Location Address
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Address Line | 500 FISHER ST
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City | KEESLER AFB
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State | MS
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Zip | 39534-2502
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Country | US
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Telephone | 228-365-5701
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Fax |
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Provider Business Mailing Address
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Address Line | 500 FISHER ST
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City | KEESLER AFB
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State | MS
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Zip | 39534-2554
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Country | US
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Telephone | 228-376-5701
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY14511
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 14511
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License Number State | CA
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