Healthcare Provider Details

I. General information

NPI: 1700064581
Provider Name (Legal Business Name): ELIZABETH K BROUGHTON MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 BONNIE ST
WILLOW SPRING NC
27592-4603
US

IV. Provider business mailing address

2233 BONNIE ST
WILLOW SPRING NC
27592-4603
US

V. Phone/Fax

Practice location:
  • Phone: 919-614-5054
  • Fax:
Mailing address:
  • Phone: 919-614-5054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number7386
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number6728
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: