Provider Demographics
NPI:1992461396
Name:BRODT, JUSTIN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BRODT
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:
Other - Last Name:BRODT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:3321 N HUSON ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-4023
Mailing Address - Country:US
Mailing Address - Phone:253-571-5468
Mailing Address - Fax:
Practice Address - Street 1:601 S 8TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4614
Practice Address - Country:US
Practice Address - Phone:253-571-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA14287090Medicaid