MEDICARE: KJIRSTEN BROUGHTON CCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1326575283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KJIRSTEN BROUGHTON CCC

Provider Business Mailing Address
First Line	:	43089 E BIG MCDONALD DR
Second Line	:
City	:	DENT
State	:	MN
Zip	:	56528-9134
Country	:	US
Telephone Number	:	907-414-7058
Fax Number	:

Provider Business Practice Location Address
First Line	:	5516 S FORT APACHE RD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-7679
Country	:	US
Telephone Number	:	702-641-8255
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2017
Last Update Date	:	05/22/2017

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Directions to “ KJIRSTEN BROUGHTON CCC” Practice Location

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