Provider Demographics
NPI:1558182063
Name:BROUGHTON, LA' TOYA
Entity type:Individual
Prefix:
First Name:LA' TOYA
Middle Name:
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2865 COUNTY ROAD 413
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-4211
Mailing Address - Country:US
Mailing Address - Phone:903-213-5407
Mailing Address - Fax:
Practice Address - Street 1:2865 COUNTY ROAD 413
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75704-4211
Practice Address - Country:US
Practice Address - Phone:903-213-5407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103T00000X, 171W00000X, 1744R1102X
TX171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No171W00000XOther Service ProvidersContractor
No1744R1102XOther Service ProvidersSpecialistResearch Study