Doctor Name: | CHARLES P BRODERICK |
NPI Number: | 1407808280 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PHD |
License Number: | PSY17352 |
Business Practice Address: | 10333 El Camino Real Atascadero, CA - 934237001 |
Business Phone Number: | 8054682000 |
Business Fax Number: | 8054666011 |
Mailing Address: | 1600 9th St, Room 205 Mailstop 2 3 SACRAMENTO |
State: | CA |
Postal Code: | 958146414 |
Phone Number: | 9166542431 |
Fax Number: | 9169543186 |
NPI Enumeration Date: | 05/17/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103G00000X |
License Number: | PSY17352 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | CA |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Clinical Neuropsychologist |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual with a doctorate degree, licensure in clinical psychology and specialized training or board certification in neuropsychology who practices or adheres to the principles of neuropsychology; a specialty within the field of psychology focusing primarily on neurobehavioral functioning. |