Provider Demographics
NPI:1669850566
Name:BRODERICK, RHEA THERESA (RT,LAC)
Entity Type:Individual
Prefix:
First Name:RHEA
Middle Name:THERESA
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:RT,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 E 45TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-1429
Mailing Address - Country:US
Mailing Address - Phone:347-927-4324
Mailing Address - Fax:
Practice Address - Street 1:1207 E 45TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-1429
Practice Address - Country:US
Practice Address - Phone:347-927-4324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25 005552171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist