Provider Demographics
NPI:1093458457
Name:BROUSSARD, LORI (OTR)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 S BROOK DR APT 1035
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-5089
Mailing Address - Country:US
Mailing Address - Phone:281-415-7832
Mailing Address - Fax:
Practice Address - Street 1:5353 WILLIAMS DR STE 100
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-2069
Practice Address - Country:US
Practice Address - Phone:512-713-0521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118669225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand