Provider Demographics
NPI:1306957022
Name:BROUSSEAU, ELENA EMILIE (PT)
Entity type:Individual
Prefix:MS
First Name:ELENA
Middle Name:EMILIE
Last Name:BROUSSEAU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELENA
Other - Middle Name:EMILIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:350 MAIN STREET
Mailing Address - Street 2:COMMERCE PLACE MCGOVERN PT
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148
Mailing Address - Country:US
Mailing Address - Phone:781-321-2727
Mailing Address - Fax:781-321-4995
Practice Address - Street 1:350 MAIN ST
Practice Address - Street 2:COMMERCE PLACE MCGOVERN PT
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5089
Practice Address - Country:US
Practice Address - Phone:781-321-2727
Practice Address - Fax:781-321-4995
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist