Provider Demographics
NPI:1528466430
Name:GENE A BRODLAND LCSW, LLC
Entity type:Organization
Organization Name:GENE A BRODLAND LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:MR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRODLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-744-3525
Mailing Address - Street 1:215 S GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3838
Mailing Address - Country:US
Mailing Address - Phone:217-744-3525
Mailing Address - Fax:217-744-3535
Practice Address - Street 1:215 S GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3838
Practice Address - Country:US
Practice Address - Phone:217-744-3525
Practice Address - Fax:217-744-3535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-002608251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL88840Medicare PIN
ILR18370Medicare UPIN