Provider Demographics
NPI:1245876515
Name:BROGLEY, ADAM THOMAS (LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:THOMAS
Last Name:BROGLEY
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 WOODLANE DR APT 5
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0280
Mailing Address - Country:US
Mailing Address - Phone:608-732-9599
Mailing Address - Fax:
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-732-9599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2211-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer