Provider Demographics
NPI:1215383682
Name:BROUSSARD, BRETT
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 TEANECK RD
Mailing Address - Street 2:STE 4A
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1086 TEANECK RD
Practice Address - Street 2:STE 4A
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4854
Practice Address - Country:US
Practice Address - Phone:201-862-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic