Provider Demographics
NPI:1891048740
Name:BROUSSARD, TIFFANY ROSHWAN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ROSHWAN
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 1:23207 SUMMER PINE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77373-6618
Mailing Address - Country:US
Mailing Address - Phone:832-206-2033
Mailing Address - Fax:
Practice Address - Street 1:23207 SUMMER PINE DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77373-6618
Practice Address - Country:US
Practice Address - Phone:832-206-2033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator