Provider Demographics
NPI:1619419249
Name:BROUSSARD, SHERRY (MA)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 W 79TH ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-4819
Mailing Address - Country:US
Mailing Address - Phone:318-688-8190
Mailing Address - Fax:318-688-8193
Practice Address - Street 1:351 W 79TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-4819
Practice Address - Country:US
Practice Address - Phone:318-688-8190
Practice Address - Fax:318-688-8193
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator