Provider Demographics
NPI:1528743960
Name:BRODIE, GWENDOLYN
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:
Last Name:BRODIE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:GWENDOLYN
Other - Middle Name:PITTMAN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:THD, PASTORAL COUNS
Mailing Address - Street 1:1360 DICK HOLEMAN RD
Mailing Address - Street 2:
Mailing Address - City:TIMBERLAKE
Mailing Address - State:NC
Mailing Address - Zip Code:27583-8875
Mailing Address - Country:US
Mailing Address - Phone:919-236-3931
Mailing Address - Fax:
Practice Address - Street 1:711 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4765
Practice Address - Country:US
Practice Address - Phone:919-236-3931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral