Provider Demographics
NPI:1689020273
Name:BRODERICK, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45 CROSSWAYS PARK DR W
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2037
Mailing Address - Country:US
Mailing Address - Phone:516-992-4568
Mailing Address - Fax:516-992-4637
Practice Address - Street 1:45 CROSSWAYS PARK DR W
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2037
Practice Address - Country:US
Practice Address - Phone:516-992-4568
Practice Address - Fax:516-992-4637
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020558225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist