Provider Demographics
NPI:1689759987
Name:BROUGHTON, GRETCHEN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 OLD ROUTE 7
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1714
Mailing Address - Country:US
Mailing Address - Phone:203-740-0020
Mailing Address - Fax:203-775-0238
Practice Address - Street 1:90 GROVE ST
Practice Address - Street 2:SUITE 106
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4114
Practice Address - Country:US
Practice Address - Phone:203-431-8471
Practice Address - Fax:203-438-9543
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008267225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V5480OtherHEALTHNET
CT11832080OtherCAQH
CT650001569Medicare PIN