Provider Demographics
NPI:1710632492
Name:BROUSSARD, MEGAN (PT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 N SHENANDOAH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:FRONT ROYAL
Mailing Address - State:VA
Mailing Address - Zip Code:22630-3643
Mailing Address - Country:US
Mailing Address - Phone:540-636-6179
Mailing Address - Fax:
Practice Address - Street 1:3127 VALLEY AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2635
Practice Address - Country:US
Practice Address - Phone:540-667-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214863225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist