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General NPI Number Information
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NPI Number | 1710313978
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Entity Type | Individual
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Provider Name | CORI DIANE BROEDLING MT, PTA
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Gender | Female
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Dates
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Enumeration Date | 09/19/2013
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Last Update Date | 01/10/2017
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Provider Practice Location Address
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Address Line | 3033 SARNO RD
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City | MELBOURNE
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State | FL
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Zip | 32934-7229
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Country | US
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Telephone | 321-610-8979
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Fax | 321-610-8980
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Provider Business Mailing Address
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Address Line | 5065 MALABAR BLVD
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City | MELBOURNE BEACH
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State | FL
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Zip | 32951-3257
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Country | US
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Telephone | 720-635-4127
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA25013
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | MT0008418
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License Number State | CO
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