Provider Demographics
NPI:1124245519
Name:BRODSKY, SHARON KAYLIE (MS OTRL)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:KAYLIE
Last Name:BRODSKY
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:
Other - Last Name:BRODSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:28 MANCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2804
Mailing Address - Country:US
Mailing Address - Phone:786-200-4025
Mailing Address - Fax:
Practice Address - Street 1:28 MANCHESTER LN
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2804
Practice Address - Country:US
Practice Address - Phone:786-200-4025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11079225X00000X
NY004251-1225XP0200X, 225X00000X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8903271Medicaid