MEDICARE: AMY BROUSSEAU

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1487065298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY BROUSSEAU

Provider Business Mailing Address
First Line	:	345A GREENWOOD ST STE B
Second Line	:	SUITE B
City	:	WORCESTER
State	:	MA
Zip	:	01607-1753
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	345A GREENWOOD ST STE B
Second Line	:	SUITE B
City	:	WORCESTER
State	:	MA
Zip	:	01607-1753
Country	:	US
Telephone Number	:	508-363-0200
Fax Number	:

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

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	05/14/2014

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Directions to “ AMY BROUSSEAU ” Practice Location

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