Provider Demographics
NPI:1831455658
Name:BROUGHTON, JUAQUINA MELITA (MS OTR)
Entity type:Individual
Prefix:
First Name:JUAQUINA
Middle Name:MELITA
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:MS OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4601 EAGLERIDGE PL STE 140
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-4101
Mailing Address - Country:US
Mailing Address - Phone:719-253-7727
Mailing Address - Fax:719-253-7729
Practice Address - Street 1:4601 EAGLERIDGE PL STE 140
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-4101
Practice Address - Country:US
Practice Address - Phone:719-253-7727
Practice Address - Fax:719-253-7729
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT-3418225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics