Provider Demographics
NPI:1386891505
Name:BROADWATER, MARY K (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:BREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:9046 PHINNEY AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-3719
Mailing Address - Country:US
Mailing Address - Phone:206-547-7445
Mailing Address - Fax:206-913-2486
Practice Address - Street 1:100 NE NORTHLAKE WAY STE 200B
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6869
Practice Address - Country:US
Practice Address - Phone:206-547-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35167225100000X
WAPT60035309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA35167OtherPHYSICAL THERAPY BOARD OF CALIFORNIA