Provider Demographics
NPI:1811414287
Name:BRODERICK, KELSEY (DPT)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:LORUSSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1931 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3506
Mailing Address - Country:US
Mailing Address - Phone:203-384-8681
Mailing Address - Fax:203-384-0722
Practice Address - Street 1:1931 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825
Practice Address - Country:US
Practice Address - Phone:203-384-8681
Practice Address - Fax:203-384-0722
Is Sole Proprietor?:No
Enumeration Date:2017-08-27
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12302225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist