Provider Demographics
NPI:1447801865
Name:BROUSSARD, SYDNEY
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
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 1:3544 SAINT JOHNS BLUFF RD S APT 922
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2674
Mailing Address - Country:US
Mailing Address - Phone:904-315-9398
Mailing Address - Fax:
Practice Address - Street 1:3544 SAINT JOHNS BLUFF RD S APT 922
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2674
Practice Address - Country:US
Practice Address - Phone:904-315-9398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator