Provider Demographics
NPI:1649773300
Name:BRODNICKI, BETH ANN (MSPT, CMLDT)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
Last Name:BRODNICKI
Suffix:
Gender:F
Credentials:MSPT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:4069 LAKE DR SE STE 114
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8816
Practice Address - Country:US
Practice Address - Phone:616-267-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist