Provider Demographics
NPI:1386696276
Name:BROYLES, ANGIE (LPP)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:BROYLES
Suffix:
Gender:F
Credentials:LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 GASTINEAU RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-5127
Mailing Address - Country:US
Mailing Address - Phone:606-423-9437
Mailing Address - Fax:606-451-6731
Practice Address - Street 1:149 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-6155
Practice Address - Country:US
Practice Address - Phone:606-679-6995
Practice Address - Fax:606-451-6731
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0046103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical