Provider Demographics
NPI:1083455869
Name:BRODERICK, LAUREN ROSE (PT, DPT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ROSE
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1871 WOODARD RD
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:NY
Mailing Address - Zip Code:14059-9366
Mailing Address - Country:US
Mailing Address - Phone:716-238-6460
Mailing Address - Fax:
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7027
Practice Address - Country:US
Practice Address - Phone:207-795-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist