Provider Demographics
NPI:1063611341
Name:BRODIE, LAURA ANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANNE
Last Name:BRODIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FISHER ST
Mailing Address - Street 2:
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2554
Mailing Address - Country:US
Mailing Address - Phone:228-376-5701
Mailing Address - Fax:
Practice Address - Street 1:500 FISHER ST
Practice Address - Street 2:
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2502
Practice Address - Country:US
Practice Address - Phone:228-365-5701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14511103TC0700X
CA14511103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty