Active NPI
Mary Ballard Broussard, OTR
- Occupational Therapist
- Conroe, TX
National Provider Identifier
1154892982
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapist
- License
- 119236
- Practice address
- 704 Longmire Rd Ste 101
Conroe, TX 77304-1850 - Phone
- (985) 373-8018
- NPI assigned
- Dec 5, 2018
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapist | 225X00000X | OTT.200764 | LA | |
| Occupational Therapist | 225X00000X | 119236 | TX | Primary |
Addresses
Primary practice location
704 Longmire Rd Ste 101
Conroe, TX 77304-1850
Mailing address
805 Yellow Birch LN
Conroe, TX 77304-1993
Phone (985) 373-8018
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| OTT.200764 | LA | MD | Occupational Therapist |
| 119236 | TX | MD | Occupational Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1543968000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1543968000000",
"number": "1154892982",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "805 YELLOW BIRCH LN",
"city": "CONROE",
"state": "TX",
"postal_code": "773041993",
"telephone_number": "985-373-8018"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "704 LONGMIRE RD STE 101",
"city": "CONROE",
"state": "TX",
"postal_code": "773041850",
"telephone_number": "985-373-8018"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BROUSSARD",
"first_name": "MARY",
"middle_name": "BALLARD",
"credential": "OTR",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2018-12-05",
"last_updated": "2018-12-05",
"status": "A"
},
"taxonomies": [
{
"code": "225X00000X",
"taxonomy_group": "",
"desc": "Occupational Therapist",
"state": "LA",
"license": "OTT.200764",
"primary": false
},
{
"code": "225X00000X",
"taxonomy_group": "",
"desc": "Occupational Therapist",
"state": "TX",
"license": "119236",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Conroe, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 5, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.