Basic Information
| Provider Information | |||||||||
| NPI: | 1114389640 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROACH | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LORIN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3455 HIGHWAY 81 SOUTH | ||||||||
| Address2: | |||||||||
| City: | LOGANVLLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300523918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705540665 | ||||||||
| FaxNumber: | 7705540685 | ||||||||
| Practice Location | |||||||||
| Address1: | 2331 SEMINOLE LN STE 103 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4324284789 | ||||||||
| FaxNumber: | 4345296985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2016 | ||||||||
| LastUpdateDate: | 12/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 291242 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | 291242 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 2305211770 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.