Provider Demographics
NPI:1134396070
Name:BRODESKE, LAURA FAIR (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:FAIR
Last Name:BRODESKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:FAIR-BRODESKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2030 E 4TH ST
Mailing Address - Street 2:SUITE 140 F
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3940
Mailing Address - Country:US
Mailing Address - Phone:714-569-9976
Mailing Address - Fax:
Practice Address - Street 1:2030 E 4TH ST
Practice Address - Street 2:SUITE 140 F
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3940
Practice Address - Country:US
Practice Address - Phone:714-569-9976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21931103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical