Provider Demographics
NPI:1447692629
Name:BROYLES, CAROLYN ANN (MS, LPC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:BROYLES
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 W PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-1447
Mailing Address - Country:US
Mailing Address - Phone:417-229-1466
Mailing Address - Fax:417-678-6530
Practice Address - Street 1:412 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-1447
Practice Address - Country:US
Practice Address - Phone:417-229-1466
Practice Address - Fax:417-678-6530
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012038135101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional