Provider Demographics
NPI:1417185604
Name:BRODEUR, PAUL (PTA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:BRODEUR
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 STOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01570-2340
Mailing Address - Country:US
Mailing Address - Phone:508-943-8337
Mailing Address - Fax:
Practice Address - Street 1:28 STOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:MA
Practice Address - Zip Code:01570-2340
Practice Address - Country:US
Practice Address - Phone:508-943-8337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2333225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA161216796OtherTAX ID