MEDICARE: MS. KIM BRODSKY LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	ES43470	NY

General Provider Information

NPI Number	:	1104218049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIM BRODSKY LMSW

Provider Business Mailing Address
First Line	:	2 DIANNE AVE
Second Line	:	COTTAGE
City	:	CENTEREACH
State	:	NY
Zip	:	11720-3635
Country	:	US
Telephone Number	:	631-648-9905
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 WHEELER RD
Second Line	:	SUITE 210
City	:	HAUPPAUGE
State	:	NY
Zip	:	11788-2964
Country	:	US
Telephone Number	:	631-361-7065
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2015
Last Update Date	:	03/02/2015

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