Provider Demographics
NPI:1346856564
Name:BROUSSARD, LENITA D (PTA)
Entity Type:Individual
Prefix:
First Name:LENITA
Middle Name:D
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 MONTGOMERY RD APT 14
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-5903
Mailing Address - Country:US
Mailing Address - Phone:979-383-4905
Mailing Address - Fax:
Practice Address - Street 1:1620 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-3546
Practice Address - Country:US
Practice Address - Phone:936-336-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2157497225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant