Provider Demographics
NPI:1710590526
Name:BROUSSARD, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403B GARDEN VILLA LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6915
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:1431 GREENWAY DR STE 500
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2444
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2025-02-07
Deactivation Date:2024-12-12
Deactivation Code:
Reactivation Date:2025-01-22
Provider Licenses
StateLicense IDTaxonomies
TXRBT-19-86197247200000X
TX121175235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other