Provider Demographics
NPI:1649792128
Name:BROYLES, KEITHA LATRICE
Entity type:Individual
Prefix:
First Name:KEITHA
Middle Name:LATRICE
Last Name:BROYLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 HIGHWAY 51 N APT 25-103
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-8720
Mailing Address - Country:US
Mailing Address - Phone:901-371-7185
Mailing Address - Fax:
Practice Address - Street 1:5281 NAVY RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-2535
Practice Address - Country:US
Practice Address - Phone:901-873-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health