Provider Demographics
NPI:1114389640
Name:BROACH, HEATHER LORIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LORIN
Last Name:BROACH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 HIGHWAY 81 SOUTH
Mailing Address - Street 2:
Mailing Address - City:LOGANVLLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-3918
Mailing Address - Country:US
Mailing Address - Phone:770-554-0665
Mailing Address - Fax:770-554-0685
Practice Address - Street 1:2331 SEMINOLE LN STE 103
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901
Practice Address - Country:US
Practice Address - Phone:432-428-4789
Practice Address - Fax:434-529-6985
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291242225100000X, 2251X0800X
VA2305211770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA197052Medicare PIN
CACA197051Medicare PIN
CACA197050Medicare PIN
CACB254498Medicare PIN