Provider Demographics
NPI:1669722617
Name:BROADSTONE, BIRGIT JENNIFER (PT)
Entity type:Individual
Prefix:
First Name:BIRGIT
Middle Name:JENNIFER
Last Name:BROADSTONE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:BROADSTONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:17077 MERIDIAN AVE N
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-5531
Mailing Address - Country:US
Mailing Address - Phone:206-393-1704
Mailing Address - Fax:206-393-1787
Practice Address - Street 1:17077 MERIDIAN AVE N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-5531
Practice Address - Country:US
Practice Address - Phone:206-393-1704
Practice Address - Fax:206-393-1787
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000035822251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics