Healthcare Provider Details

I. General information

NPI: 1891453023
Provider Name (Legal Business Name): ELIZABETH M BROUGHAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH M RANGE BS PTA

II. Dates (important events)

Enumeration Date: 12/05/2021
Last Update Date: 12/05/2021
Certification Date: 12/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2978 CENTREVILLE RD # B20171
HERNDON VA
20171-6253
US

IV. Provider business mailing address

14830 EDMAN CIR
CENTREVILLE VA
20121-4497
US

V. Phone/Fax

Practice location:
  • Phone: 703-934-5000
  • Fax:
Mailing address:
  • Phone: 845-479-0628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306605921
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: