MEDICARE: DEBRA ANN BRODIE PH.D.

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	103T00000X	Psychologist	6301006340	MI
2	103TC0700X	Clinical Psychologist	6301006340	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	38-3347895	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1518956259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA ANN BRODIE PH.D.

Provider Business Mailing Address
First Line	:	300 RIVER PLACE DR STE 5350-G
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-4457
Country	:	US
Telephone Number	:	313-871-1450
Fax Number	:	313-468-1105

Provider Business Practice Location Address
First Line	:	300 RIVER PLACE DR STE 5350-G
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-4457
Country	:	US
Telephone Number	:	313-871-1450
Fax Number	:	313-468-1105

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

Provider Enumeration Date	:	10/16/2005
Last Update Date	:	09/15/2021

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