Provider Demographics
NPI:1174979280
Name:BROSH, DEVON LAUREN
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:LAUREN
Last Name:BROSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1476 SILVER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-5075
Mailing Address - Country:US
Mailing Address - Phone:434-944-8928
Mailing Address - Fax:
Practice Address - Street 1:198 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522-4080
Practice Address - Country:US
Practice Address - Phone:434-944-8928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA01260027282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program