Provider Demographics
NPI:1790999811
Name:BROUGHAN, KATHLEEN GAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:GAY
Last Name:BROUGHAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WHARFSIDE ST
Mailing Address - Street 2:3-F
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1652
Mailing Address - Country:US
Mailing Address - Phone:843-270-7988
Mailing Address - Fax:843-723-0659
Practice Address - Street 1:2 WHARFSIDE ST
Practice Address - Street 2:3F
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1652
Practice Address - Country:US
Practice Address - Phone:843-270-7988
Practice Address - Fax:843-723-0659
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC501103TC0700X
TN548103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical