Provider Demographics
NPI:1093023764
Name:BROUSSEAU, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BROUSSEAU
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 1:404 GRAY RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-4290
Mailing Address - Country:US
Mailing Address - Phone:207-892-1840
Mailing Address - Fax:
Practice Address - Street 1:404 GRAY RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-4290
Practice Address - Country:US
Practice Address - Phone:207-892-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA979224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEOA979OtherSTATE OF MAINE BOARD OF OCCUPATIONAL THERAPY PRACTICE