Provider Demographics
NPI:1134559248
Name:BROAD, MELISSA ANN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANN
Last Name:BROAD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:NOGIEWICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:570-842-9323
Mailing Address - Fax:570-842-9362
Practice Address - Street 1:3130 PRICETOWN RD STE B
Practice Address - Street 2:
Practice Address - City:FLEETWOOD
Practice Address - State:PA
Practice Address - Zip Code:19522-8750
Practice Address - Country:US
Practice Address - Phone:484-577-4410
Practice Address - Fax:484-577-4501
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01528400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist