Provider Demographics
NPI:1265511646
Name:BRODHURST, MARIETTA (CASAC II)
Entity type:Individual
Prefix:
First Name:MARIETTA
Middle Name:
Last Name:BRODHURST
Suffix:
Gender:F
Credentials:CASAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ELMONT RD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-1603
Mailing Address - Country:US
Mailing Address - Phone:347-625-9985
Mailing Address - Fax:516-432-1796
Practice Address - Street 1:40 ELMONT RD
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-1603
Practice Address - Country:US
Practice Address - Phone:347-625-9985
Practice Address - Fax:516-432-1796
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2025-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013047101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY0033S231Medicare ID - Type Unspecified