Provider Demographics
NPI:1124418876
Name:BROUSSARD, STEVEN WILSON (L AC)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:WILSON
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 WELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-1921
Mailing Address - Country:US
Mailing Address - Phone:443-838-3141
Mailing Address - Fax:410-377-6168
Practice Address - Street 1:658 KENILWORTH DR
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2312
Practice Address - Country:US
Practice Address - Phone:443-838-3141
Practice Address - Fax:410-377-6168
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01120171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist