Provider Demographics
NPI:1891543963
Name:BROUSSARD, SHEA DENISE (MA)
Entity type:Individual
Prefix:
First Name:SHEA
Middle Name:DENISE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8610 BROMLEY RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-8017
Mailing Address - Country:US
Mailing Address - Phone:512-294-3435
Mailing Address - Fax:
Practice Address - Street 1:2011 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-1109
Practice Address - Country:US
Practice Address - Phone:512-294-3435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC630171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist