MEDICARE: KIMBERLY BROUSSARD

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	103K00000X	Behavior Analyst
2	305R00000X	Preferred Provider Organization

General Provider Information

NPI Number	:	1477908275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIMBERLY BROUSSARD

Provider Business Mailing Address
First Line	:	3380 E RUSSELL RD
Second Line	:	SUITE 104
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3402
Country	:	US
Telephone Number	:	702-476-0448
Fax Number	:	702-476-0449

Provider Business Practice Location Address
First Line	:	3380 E RUSSELL RD
Second Line	:	SUITE 104
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3402
Country	:	US
Telephone Number	:	702-476-0448
Fax Number	:	702-476-0449

Authorized Official
Title or Position	:	OWNER / OPERATOR
Name	:	MRS. KIMBERLY RASHONE BROUSSARD
Credential	:
Telephone Number	:	702-807-1718

Provider Enumeration Date	:	04/28/2016
Last Update Date	:	04/29/2016

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Directions to “KIMBERLY BROUSSARD ” Practice Location

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