Provider Demographics
NPI:1992268809
Name:BROUGHMAN, CARISSA M (LPTA)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:M
Last Name:BROUGHMAN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 SELMA LOW MOOR RD
Mailing Address - Street 2:
Mailing Address - City:LOW MOOR
Mailing Address - State:VA
Mailing Address - Zip Code:24457
Mailing Address - Country:US
Mailing Address - Phone:540-862-0068
Mailing Address - Fax:
Practice Address - Street 1:2901 SELMA- LOW MOOR RD
Practice Address - Street 2:
Practice Address - City:LOW MOOR
Practice Address - State:VA
Practice Address - Zip Code:24457-9998
Practice Address - Country:US
Practice Address - Phone:540-862-0068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603866225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant