Provider Demographics
NPI:1710144928
Name:BROYLES, CORY ALAN
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:ALAN
Last Name:BROYLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 HIGH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3613
Mailing Address - Country:US
Mailing Address - Phone:541-570-0792
Mailing Address - Fax:
Practice Address - Street 1:355 HIGH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3613
Practice Address - Country:US
Practice Address - Phone:541-570-0792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty