Provider Demographics
NPI:1740462126
Name:BROADBELT, COLIN (PT)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:BROADBELT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 ROLLING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-5227
Mailing Address - Country:US
Mailing Address - Phone:310-387-8838
Mailing Address - Fax:
Practice Address - Street 1:714 ROLLING GREEN DR
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-5227
Practice Address - Country:US
Practice Address - Phone:310-387-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWPT21930A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist