Individual
MR. DEVERY GERARD BRODDIE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMT
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
—
—
225700000X
Massage Therapist
Primary
7291
OR
372600000X
Adult Companion
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1972649903
—
OR
Enumeration date
01/29/2007
Last updated
08/31/2020
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