Provider Demographics
NPI:1689899569
Name:BROADBENT, KATHRYN E (SP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:E
Last Name:BROADBENT
Suffix:
Gender:F
Credentials:SP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:PENGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:53 CALEB ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2235
Mailing Address - Country:US
Mailing Address - Phone:207-939-7162
Mailing Address - Fax:
Practice Address - Street 1:53 CALEB ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2235
Practice Address - Country:US
Practice Address - Phone:207-939-7162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1827235Z00000X, 235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME102560200Medicaid
ME433023799OtherMAINE CARE