Basic Information
| Provider Information | |||||||||
| NPI: | 1750057360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROUSSARD | ||||||||
| FirstName: | ANDERS | ||||||||
| MiddleName: | ELLE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 703 GRANITE ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021845350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818076138 | ||||||||
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| Practice Location | |||||||||
| Address1: | 386 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021272215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177524672 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2021 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 25697 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.