Healthcare Provider Details

I. General information

NPI: 1932177680
Provider Name (Legal Business Name): SANDRA KAY BROUGHER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5114 BALCONES WOODS DR #306
AUSTIN TX
78759
US

IV. Provider business mailing address

4005 ETON LN
AUSTIN TX
78727
US

V. Phone/Fax

Practice location:
  • Phone: 512-794-8863
  • Fax: 512-795-0688
Mailing address:
  • Phone: 512-821-9935
  • Fax: 512-795-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number207738
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: