Provider Demographics
NPI:1801433958
Name:BROUSSARD, KELLY M (DPT)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:919-220-6971
Practice Address - Street 1:1168 E CUTLAR XING
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-6484
Practice Address - Country:US
Practice Address - Phone:919-332-3800
Practice Address - Fax:919-251-0421
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MD27089225100000X
NCP18088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist