Healthcare Provider Details

I. General information

NPI: 1578880753
Provider Name (Legal Business Name): MRS. LAVERNE BROUSSARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 S. I-10 SERVICE RD STE 101B
METAIRIE LA
70001-7420
US

IV. Provider business mailing address

424 HOLMES BLVD
TERRYTOWN LA
70056-2747
US

V. Phone/Fax

Practice location:
  • Phone: 504-606-8738
  • Fax: 504-304-4799
Mailing address:
  • Phone: 504-606-8738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4320
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: