Provider Demographics
NPI:1669784401
Name:BRODERICK, SUSAN H (RPT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:HAVILAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:PO BOX 1327
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-7327
Mailing Address - Country:US
Mailing Address - Phone:203-577-3700
Mailing Address - Fax:203-577-3800
Practice Address - Street 1:590 MIDDLEBURY RD
Practice Address - Street 2:SUITE A
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-2562
Practice Address - Country:US
Practice Address - Phone:203-577-3700
Practice Address - Fax:203-577-3800
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist