Provider Demographics
NPI:1588895726
Name:BROGAN, CAROL TILLEY (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:TILLEY
Last Name:BROGAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:STUARTS DRAFT
Mailing Address - State:VA
Mailing Address - Zip Code:24477-2924
Mailing Address - Country:US
Mailing Address - Phone:540-294-4556
Mailing Address - Fax:540-587-5525
Practice Address - Street 1:5 RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:STUARTS DRAFT
Practice Address - State:VA
Practice Address - Zip Code:24477-2924
Practice Address - Country:US
Practice Address - Phone:540-294-4556
Practice Address - Fax:540-587-5525
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000101224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant