Provider Demographics
NPI:1285910679
Name:BROBERG, MARC ALLEN (PT)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:ALLEN
Last Name:BROBERG
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 1:3418 LOMA VISTA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3016
Mailing Address - Country:US
Mailing Address - Phone:805-223-0508
Mailing Address - Fax:
Practice Address - Street 1:3418 LOMA VISTA RD
Practice Address - Street 2:SUITE A
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3016
Practice Address - Country:US
Practice Address - Phone:805-410-1363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-29
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA278772251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology