Provider Demographics
NPI:1376215707
Name:BROCCARDO, MARK STEVEN (COTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:BROCCARDO
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1231
Mailing Address - Country:US
Mailing Address - Phone:801-399-5609
Mailing Address - Fax:801-627-1808
Practice Address - Street 1:3430 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1231
Practice Address - Country:US
Practice Address - Phone:801-399-5609
Practice Address - Fax:801-627-1808
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8703927-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant