Provider Demographics
NPI:1124205125
Name:AULD, BRODIE GLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:BRODIE
Middle Name:GLEN
Last Name:AULD
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 1:1045 LAS GALLINAS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2464
Mailing Address - Country:US
Mailing Address - Phone:510-213-2700
Mailing Address - Fax:
Practice Address - Street 1:4655 RUFFNER ST
Practice Address - Street 2:SUITE 270
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92177
Practice Address - Country:US
Practice Address - Phone:800-787-6787
Practice Address - Fax:800-787-6762
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist