Basic Information
| Provider Information | |||||||||
| NPI: | 1720752553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1002 WISHARD BLVD STE 4110 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462024164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179448162 | ||||||||
| FaxNumber: | 3179484848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2021 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 20043498A | IN | N | Behavioral Health & Social Service Providers | Psychologist | 103TB0200X | 20043498A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
No ID Information.