Provider Demographics
NPI:1336489194
Name:BROADLEY, GABRIELLE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:BROADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 DAVENPORT TER
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994-1334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 DAVENPORT TER
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-1334
Practice Address - Country:US
Practice Address - Phone:845-558-0236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007880-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant