Healthcare Provider Details

I. General information

NPI: 1063036291
Provider Name (Legal Business Name): MELISSA BETH BROUSSEAU L., ATC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PAYSON AVE
EASTHAMPTON MA
01027-2246
US

IV. Provider business mailing address

220 MAIN ST APT 1
EASTHAMPTON MA
01027-2025
US

V. Phone/Fax

Practice location:
  • Phone: 413-529-3089
  • Fax:
Mailing address:
  • Phone: 413-626-9709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1004
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: