Provider Demographics
NPI:1063036291
Name:BROUSSEAU, MELISSA BETH (L, ATC)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:BETH
Last Name:BROUSSEAU
Suffix:
Gender:F
Credentials:L, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 MAIN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:EASTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-2025
Mailing Address - Country:US
Mailing Address - Phone:413-626-9709
Mailing Address - Fax:
Practice Address - Street 1:19 PAYSON AVE
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-2246
Practice Address - Country:US
Practice Address - Phone:413-529-3089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty