Provider Demographics
NPI:1972649903
Name:BRODDIE, DEVERY GERARD (LMT)
Entity Type:Individual
Prefix:MR
First Name:DEVERY
Middle Name:GERARD
Last Name:BRODDIE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 OAK ST, STE 200
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031
Mailing Address - Country:US
Mailing Address - Phone:541-386-0009
Mailing Address - Fax:
Practice Address - Street 1:315 OAK ST. STE 200
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031
Practice Address - Country:US
Practice Address - Phone:541-386-0009
Practice Address - Fax:541-386-0029
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 372600000X
OR7291225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1972649903Medicaid