Provider Demographics
NPI:1679648109
Name:BROUSSARD, LATRESIA GRACE (DC)
Entity Type:Individual
Prefix:DR
First Name:LATRESIA
Middle Name:GRACE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:NEW ROADS
Mailing Address - State:LA
Mailing Address - Zip Code:70760-2622
Mailing Address - Country:US
Mailing Address - Phone:225-618-8016
Mailing Address - Fax:225-618-8028
Practice Address - Street 1:331 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEW ROADS
Practice Address - State:LA
Practice Address - Zip Code:70760-2622
Practice Address - Country:US
Practice Address - Phone:225-618-8016
Practice Address - Fax:225-618-8028
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1307111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1509060Medicaid
LAU85337Medicare UPIN
LA1509060Medicaid