Provider Demographics
NPI:1710131461
Name:BRODERICK, MELISSA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:11 STONEHOLLOW DRIVE
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-2678
Mailing Address - Country:US
Mailing Address - Phone:914-364-0504
Mailing Address - Fax:914-828-0100
Practice Address - Street 1:2900 WESTCHESTER AVENUE
Practice Address - Street 2:SUITE 108
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2552
Practice Address - Country:US
Practice Address - Phone:914-364-0504
Practice Address - Fax:914-828-0100
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0257232251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY20-4713808OtherITIN