Provider Demographics
NPI:1285106880
Name:BRODIE WALKER, STACEY NICOLE ALVIA
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:NICOLE ALVIA
Last Name:BRODIE WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9916 NOB HILL LN
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-4665
Mailing Address - Country:US
Mailing Address - Phone:754-801-9750
Mailing Address - Fax:
Practice Address - Street 1:150 S PINE ISLAND RD STE 300
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2665
Practice Address - Country:US
Practice Address - Phone:754-801-9750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8168103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling