Provider Demographics
NPI:1295868909
Name:BRODERICK, LORI (OTR)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 WOODFORD DR
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2123
Mailing Address - Country:US
Mailing Address - Phone:413-297-2921
Mailing Address - Fax:
Practice Address - Street 1:61 COOPER ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-2149
Practice Address - Country:US
Practice Address - Phone:413-786-8000
Practice Address - Fax:413-789-2359
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3104225X00000X
FL20399225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist