Provider Demographics
NPI:1275012114
Name:BROUSSARD, VICTORIA NOEL (OTR)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:NOEL
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 OLD GRANGER
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-3564
Mailing Address - Country:US
Mailing Address - Phone:512-352-6337
Mailing Address - Fax:
Practice Address - Street 1:1810 OLD GRANGER
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-3564
Practice Address - Country:US
Practice Address - Phone:512-352-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118861225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist