Provider Demographics
NPI:1912460890
Name:BROGAN, LAURIE (PT, DPT, CEEAA, GCS)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:BROGAN
Suffix:
Gender:F
Credentials:PT, DPT, CEEAA, GCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 SUSCON RD
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-9541
Mailing Address - Country:US
Mailing Address - Phone:570-362-4201
Mailing Address - Fax:
Practice Address - Street 1:5 JACQUELYN LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-9107
Practice Address - Country:US
Practice Address - Phone:570-255-4578
Practice Address - Fax:570-255-4575
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT014115L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty