Provider Demographics
NPI:1376340281
Name:BROUSSARD, MANDY
Entity type:Individual
Prefix:
First Name:MANDY
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 1:1111 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MC COOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-2625
Mailing Address - Country:US
Mailing Address - Phone:720-292-7903
Mailing Address - Fax:
Practice Address - Street 1:506 E 12TH ST
Practice Address - Street 2:
Practice Address - City:MC COOK
Practice Address - State:NE
Practice Address - Zip Code:69001-3599
Practice Address - Country:US
Practice Address - Phone:308-745-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470563788Medicaid