Provider Demographics
NPI:1700928322
Name:BROUSSARD, BRIDGET
Entity Type:Individual
Prefix:
First Name:BRIDGET
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 1:100 WESTMARK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-7344
Mailing Address - Country:US
Mailing Address - Phone:337-989-9745
Mailing Address - Fax:
Practice Address - Street 1:100 WESTMARK BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-7344
Practice Address - Country:US
Practice Address - Phone:337-989-9745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3685235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist