Basic Information
Provider Information
NPI: 1003014408
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BROUSSARD
FirstName: AVERIL
MiddleName:  
NamePrefix: MS.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 19115 S WHIMSEY DR
Address2:  
City: CYPRESS
State: TX
PostalCode: 774332130
CountryCode: US
TelephoneNumber: 2816901979
FaxNumber:  
Practice Location
Address1: 19115 S WHIMSEY DR
Address2:  
City: CYPRESS
State: TX
PostalCode: 774332130
CountryCode: US
TelephoneNumber: 2816901979
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/06/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
247200000X156149TXY Technologists, Technicians & Other Technical Service ProvidersTechnician, Other 

No ID Information.


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