Active NPI
Debra Jean Broderick, PYS.D.
- Counseling Psychologist
- Saint Paul, MN
National Provider Identifier
1639204423
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Counseling Psychologist
- License
- 4744
- Practice address
- 357 Kellogg Blvd E
Saint Paul, MN 55101-1411 - Phone
- (651) 295-1422
- NPI assigned
- Feb 22, 2007
- Last updated
- Jul 8, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counseling Psychologist | 103TC1900X | 4744 | MN | Primary |
Addresses
Primary practice location
357 Kellogg Blvd E
Saint Paul, MN 55101-1411
Mailing address
1434 Simpson St
Saint Paul, MN 55108-2440
Phone (651) 645-3998
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4744 | MN | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172102400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1639204423",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1434 SIMPSON ST",
"city": "SAINT PAUL",
"state": "MN",
"postal_code": "551082440",
"telephone_number": "651-645-3998"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "357 KELLOGG BLVD E",
"city": "SAINT PAUL",
"state": "MN",
"postal_code": "551011411",
"telephone_number": "651-295-1422"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BRODERICK",
"first_name": "DEBRA",
"middle_name": "JEAN",
"name_prefix": "Dr.",
"credential": "PYS.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-02-22",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC1900X",
"taxonomy_group": "",
"desc": "Psychologist, Counseling",
"state": "MN",
"license": "4744",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Saint Paul, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.