=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457564700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH BRODSKY LIST JUDITH BRODSKY LIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 09/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4919 BETHESDA AVE SUITE 202
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814-5203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-656-3644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11042 SEVEN HILL LN
-----------------------------------------------------
City | POTOMAC
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20854-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-299-4135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4999
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------