Provider Demographics
NPI:1003621251
Name:BROOKLYN RODDENBERRY, LCSW, LLC
Entity type:Organization
Organization Name:BROOKLYN RODDENBERRY, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKLYN
Authorized Official - Middle Name:LOVE
Authorized Official - Last Name:RODDENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:850-519-3928
Mailing Address - Street 1:5332 FALLING STAR DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-7823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 JOHN KNOX ROAD
Practice Address - Street 2:BUILDING T, SUITE 1
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303
Practice Address - Country:US
Practice Address - Phone:850-270-7099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)