Healthcare Provider Details

I. General information

NPI: 1417185604
Provider Name (Legal Business Name): PAUL BRODEUR PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 STOUGHTON AVE
WEBSTER MA
01570-2340
US

IV. Provider business mailing address

28 STOUGHTON AVE
WEBSTER MA
01570-2340
US

V. Phone/Fax

Practice location:
  • Phone: 508-943-8337
  • Fax:
Mailing address:
  • Phone: 508-943-8337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2333
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: