Provider Demographics
NPI:1386164002
Name:BROHARD, CARLY MARIE (DPT)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:MARIE
Last Name:BROHARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:CALDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17 EDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1050
Practice Address - Country:US
Practice Address - Phone:304-927-6249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPT003883OtherWV BOARD OF PHYSICAL THERAPY