Active NPI
Kennedi Broussard
- Behavior Technician
- San Diego, CA
National Provider Identifier
1639835275
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Behavior Technician
- Practice address
- 3878 Ruffin Rd Ste B
San Diego, CA 92123-1842 - Phone
- (619) 795-9925
- NPI assigned
- Nov 9, 2021
- Last updated
- Nov 15, 2021
- 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 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Behavior Technician | 106S00000X | Primary |
Addresses
Primary practice location
3878 Ruffin Rd Ste B
San Diego, CA 92123-1842
Mailing address
8885 Rio San Diego Dr Ste 340
San Diego, CA 92108-1669
Phone (619) 795-9925
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
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mebe San Diego | Behavior Technician | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1636416000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1636934400000",
"number": "1639835275",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "8885 RIO SAN DIEGO DR STE 340",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921081669",
"telephone_number": "619-795-9925",
"fax_number": "877-602-5087"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3878 RUFFIN RD STE B",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921231842",
"telephone_number": "619-795-9925"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BROUSSARD",
"first_name": "KENNEDI",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2021-11-09",
"last_updated": "2021-11-15",
"certification_date": "2021-11-15",
"status": "A"
},
"taxonomies": [
{
"code": "106S00000X",
"taxonomy_group": "",
"desc": "Behavior Technician",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.