Provider Demographics
NPI:1356555163
Name:BROUSSARD, MORGAN ORTEGO (LOTR)
Entity type:Individual
Prefix:MRS
First Name:MORGAN
Middle Name:ORTEGO
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:MISS
Other - First Name:MORGAN
Other - Middle Name:ELISE
Other - Last Name:ORTEGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LOTR
Mailing Address - Street 1:313 HERLIL CIR
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-5518
Mailing Address - Country:US
Mailing Address - Phone:337-739-5837
Mailing Address - Fax:337-896-2970
Practice Address - Street 1:313 HERLIL CIR
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-5518
Practice Address - Country:US
Practice Address - Phone:337-739-5837
Practice Address - Fax:337-896-2970
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ12122225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1304026Medicaid