Provider Demographics
NPI:1740371707
Name:BROADWELL, SARA LYNN (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:LYNN
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 MASON ST
Mailing Address - Street 2:
Mailing Address - City:MORRISONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12962-2700
Mailing Address - Country:US
Mailing Address - Phone:518-561-6888
Mailing Address - Fax:
Practice Address - Street 1:882 MASON ST
Practice Address - Street 2:
Practice Address - City:MORRISONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12962-2700
Practice Address - Country:US
Practice Address - Phone:518-561-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008917-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01021181Medicaid
NY000415107001OtherBLUESHIELD OF NENY
NY000415107001OtherBLUESHIELD OF NENY