Provider Demographics
NPI:1497291918
Name:BROYLES, KATIE JOHNSON (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:JOHNSON
Last Name:BROYLES
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 TRINITY RD
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-6856
Mailing Address - Country:US
Mailing Address - Phone:540-797-2544
Mailing Address - Fax:
Practice Address - Street 1:1110 MARSHALL RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4216
Practice Address - Country:US
Practice Address - Phone:888-298-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-08
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007043235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist