Provider Demographics
NPI:1306821764
Name:BROUSSARD, JAMES KEITH (PT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:KEITH
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MANY
Mailing Address - State:LA
Mailing Address - Zip Code:71449-3717
Mailing Address - Country:US
Mailing Address - Phone:318-256-6285
Mailing Address - Fax:318-256-6658
Practice Address - Street 1:295 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-3717
Practice Address - Country:US
Practice Address - Phone:318-256-6285
Practice Address - Fax:318-256-6658
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C335Medicare ID - Type Unspecified