Provider Demographics
NPI:1033621222
Name:BROGDEN, PHILIP (LMT)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:BROGDEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14028 N HIGHWAY 183 STE D120
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-5992
Mailing Address - Country:US
Mailing Address - Phone:512-250-8800
Mailing Address - Fax:
Practice Address - Street 1:14028 N HIGHWAY 183 STE D120
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-5992
Practice Address - Country:US
Practice Address - Phone:512-250-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-29
Last Update Date:2017-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT121606225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT121606OtherLMT