Provider Demographics
NPI:1104002617
Name:BROUSSARD, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:BROUSSARD
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 1:470 CLOVERLEAF DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-2917
Mailing Address - Country:US
Mailing Address - Phone:972-754-2084
Mailing Address - Fax:972-218-9195
Practice Address - Street 1:470 CLOVERLEAF DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-2917
Practice Address - Country:US
Practice Address - Phone:972-754-2084
Practice Address - Fax:972-218-9195
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator