Healthcare Provider Details

I. General information

NPI: 1326655515
Provider Name (Legal Business Name): THOMAS EDWIN BROYLES LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 E ANDERSON LN STE 120
AUSTIN TX
78752-1236
US

IV. Provider business mailing address

1700 ARIAL DR
AUSTIN TX
78753-7340
US

V. Phone/Fax

Practice location:
  • Phone: 512-961-5575
  • Fax:
Mailing address:
  • Phone: 512-953-5954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number84236
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: