Provider Demographics
NPI:1619077625
Name:BRODEN, CINDY (RPT)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:
Last Name:BRODEN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:CINDY
Other - Middle Name:
Other - Last Name:WIELAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:1300 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-2300
Practice Address - Fax:763-689-5558
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54438Medicaid
MN066R2BROtherBLUE CROSS BLUE SHIELD
MN616055700Medicaid
ND15467OtherBLUE CROSS BLUE SHIELD
MN6411181OtherMEDICA