Provider Demographics
NPI:1750809448
Name:BROUSSARD, BRIAN PAUL (DPT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:PAUL
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 2ND AVE NE STE 1401
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3480
Mailing Address - Country:US
Mailing Address - Phone:727-258-7224
Mailing Address - Fax:
Practice Address - Street 1:111 2ND AVE NE STE 1401
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3480
Practice Address - Country:US
Practice Address - Phone:727-258-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-02
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA16797194212251S0007X
FLPT340622251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports