Provider Demographics
NPI:1538124011
Name:MEWBORN-BROADUS, MARY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:MEWBORN-BROADUS
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 1:11456 212TH ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11411-1018
Mailing Address - Country:US
Mailing Address - Phone:718-526-1000
Mailing Address - Fax:718-298-8531
Practice Address - Street 1:17900 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11425-0001
Practice Address - Country:US
Practice Address - Phone:718-526-1000
Practice Address - Fax:718-298-8531
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist