Healthcare Provider Details

I. General information

NPI: 1396445540
Provider Name (Legal Business Name): EMILY LAUREN BROYLES OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 DEER RUN RD
DANVILLE VA
24540-2863
US

IV. Provider business mailing address

1665 WHITMELL SCHOOL RD
DRY FORK VA
24549-3827
US

V. Phone/Fax

Practice location:
  • Phone: 434-797-5531
  • Fax: 434-797-5529
Mailing address:
  • Phone: 434-203-0970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119009842
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: