Provider Demographics
NPI:1770763559
Name:BROUSSARD, CRYSTAL MARIE (AUD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:MARIE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:MARIE
Other - Last Name:GOETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:16251 N CLEVELAND AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-2176
Mailing Address - Country:US
Mailing Address - Phone:239-997-8288
Mailing Address - Fax:239-997-8084
Practice Address - Street 1:16251 N CLEVELAND AVE STE 8
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-2176
Practice Address - Country:US
Practice Address - Phone:239-997-8288
Practice Address - Fax:239-997-8084
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1198237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL600400800Medicaid
UI374ZMedicare PIN