Provider Demographics
NPI:1164046637
Name:BROYLES, JUDY LYNN
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:LYNN
Last Name:BROYLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1088 N WILLOW OAK RD
Mailing Address - Street 2:
Mailing Address - City:GLADEWATER
Mailing Address - State:TX
Mailing Address - Zip Code:75647-7811
Mailing Address - Country:US
Mailing Address - Phone:903-714-3099
Mailing Address - Fax:
Practice Address - Street 1:1088 N WILLOW OAK RD
Practice Address - Street 2:
Practice Address - City:GLADEWATER
Practice Address - State:TX
Practice Address - Zip Code:75647-7811
Practice Address - Country:US
Practice Address - Phone:903-714-3099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1316559321Medicaid