Provider Demographics
NPI:1407923998
Name:BROUSSARD, PHILOMENA C (DPT, MPHA, BSPT)
Entity Type:Individual
Prefix:MRS
First Name:PHILOMENA
Middle Name:C
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:DPT, MPHA, BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 ANDREW AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-1802
Mailing Address - Country:US
Mailing Address - Phone:228-762-2345
Mailing Address - Fax:228-762-2365
Practice Address - Street 1:2838 ANDREW AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-1802
Practice Address - Country:US
Practice Address - Phone:228-762-2345
Practice Address - Fax:228-762-2365
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0308174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist