Provider Demographics
NPI:1770624090
Name:BROUSSARD, VICTORIA LYNN (LPT)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:LYNN
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 BRESEE AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-2414
Mailing Address - Country:US
Mailing Address - Phone:626-337-0747
Mailing Address - Fax:
Practice Address - Street 1:4600 BRESEE AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-2414
Practice Address - Country:US
Practice Address - Phone:626-337-0747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19904167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician