Provider Demographics
NPI:1629204029
Name:BROADHURST, LAURA DIANE
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:DIANE
Last Name:BROADHURST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:DIANE
Other - Last Name:HELSBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14444 BEACH BLVD
Mailing Address - Street 2:#500
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2079
Mailing Address - Country:US
Mailing Address - Phone:904-858-7510
Mailing Address - Fax:
Practice Address - Street 1:14444 BEACH BLVD
Practice Address - Street 2:#500
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-2079
Practice Address - Country:US
Practice Address - Phone:904-858-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-31
Last Update Date:2009-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4759235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist