Provider Demographics
NPI:1023115763
Name:BROUSSARD, CRAIG ROBERT (LOTR)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ROBERT
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 BRIARMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7210
Mailing Address - Country:US
Mailing Address - Phone:337-303-3237
Mailing Address - Fax:
Practice Address - Street 1:1021 E LAUREL AVE
Practice Address - Street 2:
Practice Address - City:EUNICE
Practice Address - State:LA
Practice Address - Zip Code:70535-3611
Practice Address - Country:US
Practice Address - Phone:337-546-0101
Practice Address - Fax:337-546-0071
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11165225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist