Provider Demographics
NPI:1780980920
Name:BROYLES, MARLO CAMILLE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:MARLO
Middle Name:CAMILLE
Last Name:BROYLES
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 ASHLAND WAY
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9112
Mailing Address - Country:US
Mailing Address - Phone:910-399-1683
Mailing Address - Fax:
Practice Address - Street 1:3620 HAPPY WOODS CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-2925
Practice Address - Country:US
Practice Address - Phone:843-293-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-06
Last Update Date:2011-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7592224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant