Provider Demographics
NPI:1578690913
Name:BROUSSARD, BLAISE F (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:BLAISE
Middle Name:F
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:BLAISE
Other - Middle Name:F
Other - Last Name:BROUSSARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:309 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4861
Mailing Address - Country:US
Mailing Address - Phone:337-462-6097
Mailing Address - Fax:337-462-0531
Practice Address - Street 1:1085 LANDRENEAU ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:LA
Practice Address - Zip Code:70589-9102
Practice Address - Country:US
Practice Address - Phone:337-348-9950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist