Provider Demographics
NPI:1336224690
Name:BROADWELL, MARY WORLDS (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:WORLDS
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GUY RD
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-7205
Mailing Address - Country:US
Mailing Address - Phone:919-553-8185
Mailing Address - Fax:919-553-0187
Practice Address - Street 1:400 GUY RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-7205
Practice Address - Country:US
Practice Address - Phone:919-553-8185
Practice Address - Fax:919-553-0187
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC07762OtherBCBS PROVIDER NUMBER
NC7207762/7200094Medicaid
NC7207762/7200094Medicaid