Provider Demographics
NPI:1013992577
Name:BROUSSARD, CLEON SHERRILL (PT)
Entity Type:Individual
Prefix:MRS
First Name:CLEON
Middle Name:SHERRILL
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CLEON
Other - Middle Name:SHERRILL
Other - Last Name:GROOMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:9224 BRAMBLE RD
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-8712
Mailing Address - Country:US
Mailing Address - Phone:517-438-2169
Mailing Address - Fax:
Practice Address - Street 1:9224 BRAMBLE RD
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-8712
Practice Address - Country:US
Practice Address - Phone:517-438-2169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010070192251S0007X, 2251X0800X, 2251P0200X, 225100000X, 2251G0304X, 2251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOPO6230Medicare ID - Type Unspecified