Provider Demographics
NPI:1891453023
Name:BROUGHAL, ELIZABETH M
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:BROUGHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:M
Other - Last Name:RANGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS PTA
Mailing Address - Street 1:14830 EDMAN CIR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-4497
Mailing Address - Country:US
Mailing Address - Phone:845-479-0628
Mailing Address - Fax:
Practice Address - Street 1:2978 CENTREVILLE RD # B20171
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-6253
Practice Address - Country:US
Practice Address - Phone:703-934-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-05
Last Update Date:2021-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605921225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant