Provider Demographics
NPI:1043701279
Name:BRODERICK, SHERRI (LMT)
Entity Type:Individual
Prefix:
First Name:SHERRI
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-0756
Mailing Address - Country:US
Mailing Address - Phone:541-241-0043
Mailing Address - Fax:
Practice Address - Street 1:325 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-5047
Practice Address - Country:US
Practice Address - Phone:541-549-3534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15583225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist