Basic Information
| Provider Information | |||||||||
| NPI: | 1679668883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROGDEN | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW, BCD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 508 FULTON ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277053875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192860411 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 508 FULTON ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277053875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192860411 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW003333 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.