Healthcare Provider Details

I. General information

NPI: 1205232550
Provider Name (Legal Business Name): MR. TERRANCE BROUSSARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12672 FEDERAL PL
FISHERS IN
46037-7833
US

IV. Provider business mailing address

12672 FEDERAL PL
FISHERS IN
46037-7833
US

V. Phone/Fax

Practice location:
  • Phone: 317-374-4102
  • Fax:
Mailing address:
  • Phone: 317-374-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number991572
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: