Provider Demographics
NPI:1417663881
Name:BROUSSARD, ALYSSA MARIE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9950 PENION CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-6286
Mailing Address - Country:US
Mailing Address - Phone:916-667-2559
Mailing Address - Fax:
Practice Address - Street 1:9950 PENION CT
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-6286
Practice Address - Country:US
Practice Address - Phone:916-667-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90884108GMedicaid