MEDICARE: THERESE LISIEUX BRODERICK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1730731225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESE LISIEUX BRODERICK

Provider Business Mailing Address
First Line	:	391 W LAWRENCE ST
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12208-2135
Country	:	US
Telephone Number	:	518-482-2639
Fax Number	:	518-482-2639

Provider Business Practice Location Address
First Line	:	391 W LAWRENCE ST
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12208-2135
Country	:	US
Telephone Number	:	518-482-2639
Fax Number	:	518-482-2639

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2019
Last Update Date	:	07/15/2019

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