MEDICARE: MS. ELENA EMILIE BROUSSEAU PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	8650	MA

General Provider Information

NPI Number	:	1306957022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELENA EMILIE BROUSSEAU PT

Provider Business Mailing Address
First Line	:	350 MAIN STREET
Second Line	:	COMMERCE PLACE MCGOVERN PT
City	:	MALDEN
State	:	MA
Zip	:	02148
Country	:	US
Telephone Number	:	781-321-2727
Fax Number	:	781-321-4995

Provider Business Practice Location Address
First Line	:	350 MAIN ST
Second Line	:	COMMERCE PLACE MCGOVERN PT
City	:	MALDEN
State	:	MA
Zip	:	02148-5089
Country	:	US
Telephone Number	:	781-321-2727
Fax Number	:	781-321-4995

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	03/22/2013

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