Provider Demographics
NPI:1932327244
Name:BROAD, AUDREY FERN
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:FERN
Last Name:BROAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 BROOKDALE CT
Mailing Address - Street 2:
Mailing Address - City:DRESHER
Mailing Address - State:PA
Mailing Address - Zip Code:19025-1516
Mailing Address - Country:US
Mailing Address - Phone:215-591-9348
Mailing Address - Fax:
Practice Address - Street 1:905 PENLLYN PIKE
Practice Address - Street 2:
Practice Address - City:SPRINGHOUSE
Practice Address - State:PA
Practice Address - Zip Code:19477
Practice Address - Country:US
Practice Address - Phone:215-646-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL001215L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist