Provider Demographics
NPI:1922361336
Name:BROY, KATHLEEN IRENE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:IRENE
Last Name:BROY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:BROY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5001 STATESMAN DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2414
Mailing Address - Country:US
Mailing Address - Phone:877-840-5157
Mailing Address - Fax:
Practice Address - Street 1:5778 CHAPIN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:WI
Practice Address - Zip Code:54121-9443
Practice Address - Country:US
Practice Address - Phone:715-528-4833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003739235Z00000X
CA15670235Z00000X
WI1834-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist