Provider Demographics
NPI:1154765766
Name:BROADHEAD, MARK ROBERT (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:BROADHEAD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 SMOKEY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-581-5709
Mailing Address - Fax:
Practice Address - Street 1:510 S 14TH ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-3731
Practice Address - Country:US
Practice Address - Phone:406-222-0672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5784225100000X
CO8145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist