Provider Demographics
NPI:1578651832
Name:BRODBECK, CHRISTINA ELIZABETH (PT, MSPT)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ELIZABETH
Last Name:BRODBECK
Suffix:
Gender:F
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:ELIZABETH
Other - Last Name:ROOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47020 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2077
Mailing Address - Country:US
Mailing Address - Phone:760-777-8377
Mailing Address - Fax:760-777-9377
Practice Address - Street 1:12139 MOUNT VERNON AVE
Practice Address - Street 2:110
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5586
Practice Address - Country:US
Practice Address - Phone:909-370-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA142418Medicare PIN
CACA154699Medicare PIN
CACB228023Medicare PIN