Provider Demographics
NPI:1154200665
Name:BROADBENT, MARY (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BROADBENT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 PINE DEL DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86005-9603
Mailing Address - Country:US
Mailing Address - Phone:973-767-3671
Mailing Address - Fax:
Practice Address - Street 1:460 N SWITZER CANYON DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4899
Practice Address - Country:US
Practice Address - Phone:928-440-3106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-28
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist