Provider Demographics
NPI:1922763515
Name:BROADDUS, BRANDI (COTA/L)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:BROADDUS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MOLLY DR
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:IL
Mailing Address - Zip Code:62640-9580
Mailing Address - Country:US
Mailing Address - Phone:217-652-4021
Mailing Address - Fax:
Practice Address - Street 1:3131 GREENHEAD DR STE D
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7426
Practice Address - Country:US
Practice Address - Phone:217-891-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005546224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL057005546OtherCOTA