Basic Information
| Provider Information | |||||||||
| NPI: | 1699229427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODSKY | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | CLAIRE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 MARILYN DR | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140722632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162970798 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 MARILYN DR | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140722632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162970798 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2016 | ||||||||
| LastUpdateDate: | 08/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 1402313 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1402313 | 01 | NY | NEW YORK STATE LICENSE | OTHER |