Provider Demographics
NPI:1689651705
Name:BROYLES, JIM RAY (PHD)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:RAY
Last Name:BROYLES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3796 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123
Mailing Address - Country:US
Mailing Address - Phone:614-871-0035
Mailing Address - Fax:614-539-0069
Practice Address - Street 1:3796 BROADWAY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123
Practice Address - Country:US
Practice Address - Phone:614-871-0035
Practice Address - Fax:614-539-0069
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5180103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling