Provider Demographics
NPI:1417371840
Name:BRODERICK, DEBRA LYNN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN
Last Name:BRODERICK
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 1:4099 SPAIN FERRY RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-9119
Mailing Address - Country:US
Mailing Address - Phone:229-561-4767
Mailing Address - Fax:229-890-3397
Practice Address - Street 1:2410 W PLAZA DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5325
Practice Address - Country:US
Practice Address - Phone:850-385-6185
Practice Address - Fax:850-385-2580
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003216225200000X
FLPTA32057225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA32057OtherFLORIDA BOARD OF PHYSICAL THERAPY
GAPTA003216OtherPHYSICAL THERAPY ASSISTANT