Provider Demographics
NPI:1144576851
Name:BROADBENT, MATILDE (MSED)
Entity type:Individual
Prefix:
First Name:MATILDE
Middle Name:
Last Name:BROADBENT
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 PROSPECT AVE APT 3E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-6825
Mailing Address - Country:US
Mailing Address - Phone:646-316-2390
Mailing Address - Fax:
Practice Address - Street 1:1815 PROSPECT AVE
Practice Address - Street 2:APT 3E
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:646-316-2390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist