Provider Demographics
NPI:1578880753
Name:BROUSSARD, LAVERNE
Entity Type:Individual
Prefix:MRS
First Name:LAVERNE
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 1:424 HOLMES BLVD
Mailing Address - Street 2:
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-2747
Mailing Address - Country:US
Mailing Address - Phone:504-606-8738
Mailing Address - Fax:
Practice Address - Street 1:4300 S. I-10 SERVICE RD
Practice Address - Street 2:STE 101B
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-7420
Practice Address - Country:US
Practice Address - Phone:504-606-8738
Practice Address - Fax:504-304-4799
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL173C00000X
LA4320225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist