Provider Demographics
NPI:1548349996
Name:ADESEGUN, BROADWIN B (DPT)
Entity type:Individual
Prefix:MS
First Name:BROADWIN
Middle Name:B
Last Name:ADESEGUN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BROADWIN
Other - Middle Name:B
Other - Last Name:DANKWAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:657 NATHANIEL CHASE LN
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4970
Mailing Address - Country:US
Mailing Address - Phone:703-826-3743
Mailing Address - Fax:206-339-2959
Practice Address - Street 1:43490 YUKON DR STE 212
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-7326
Practice Address - Country:US
Practice Address - Phone:703-729-7920
Practice Address - Fax:703-729-7923
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204402225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist