Basic Information
| Provider Information | |||||||||
| NPI: | 1235866906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROUILLETTE | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 120 HIDDEN PATH DR | ||||||||
| Address2: | |||||||||
| City: | PINEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713602202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187940419 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3600 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713033040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186257050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2022 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 0994 | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0994 | 01 | LA | LAST FOUR | OTHER |