Provider Demographics
NPI:1639611643
Name:BROYLES, KELLY (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BROYLES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 N PATTERSON ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2597
Mailing Address - Country:US
Mailing Address - Phone:229-244-1707
Mailing Address - Fax:
Practice Address - Street 1:2200 N PATTERSON ST
Practice Address - Street 2:SUITE D
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2597
Practice Address - Country:US
Practice Address - Phone:229-244-1707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001514106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist