Provider Demographics
NPI:1710313978
Name:BROEDLING, CORI DIANE (MT, PTA)
Entity Type:Individual
Prefix:MISS
First Name:CORI
Middle Name:DIANE
Last Name:BROEDLING
Suffix:
Gender:F
Credentials:MT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5065 MALABAR BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3257
Mailing Address - Country:US
Mailing Address - Phone:720-635-4127
Mailing Address - Fax:
Practice Address - Street 1:3033 SARNO RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7229
Practice Address - Country:US
Practice Address - Phone:321-610-8979
Practice Address - Fax:321-610-8980
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25013225200000X
COMT0008418172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No172V00000XOther Service ProvidersCommunity Health Worker