Provider Demographics
NPI:1588854079
Name:BROADHURST, THELMA DIANE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:THELMA
Middle Name:DIANE
Last Name:BROADHURST
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 MARIETTA ST.
Mailing Address - Street 2:P. O. BOX 86
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263-0086
Mailing Address - Country:US
Mailing Address - Phone:318-428-3659
Mailing Address - Fax:318-428-3659
Practice Address - Street 1:604 MARIETTA ST.
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263-0086
Practice Address - Country:US
Practice Address - Phone:318-428-3659
Practice Address - Fax:318-428-3659
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1302082Medicaid