=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275147829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLISON R BROYLES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2020
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 UPTOWN BLVD FL 2
-----------------------------------------------------
City | CEDAR HILL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75104-3527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-899-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2050 CONQUEST BLVD APT 3302
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75167-4862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-899-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MRS. ALLISON RENE BROYLES
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 817-899-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------