Provider Demographics
NPI:1235431370
Name:BROUSSEAU, JUSTIN LEE (LMT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:LEE
Last Name:BROUSSEAU
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7016
Mailing Address - Country:US
Mailing Address - Phone:207-344-8385
Mailing Address - Fax:
Practice Address - Street 1:183 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7016
Practice Address - Country:US
Practice Address - Phone:207-344-8385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4322225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMT4322OtherMASSAGE THERAPIST