Provider Demographics
NPI:1710634852
Name:BROUSSARD, KENNEDY
Entity Type:Individual
Prefix:
First Name:KENNEDY
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 1:8601 ANDERSON MILL RD APT 1524
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-4732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1613 DUBIEL DR
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-4212
Practice Address - Country:US
Practice Address - Phone:337-526-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist