Provider Demographics
NPI:1447899380
Name:BROSSEAU, WALTER EDWARD
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:EDWARD
Last Name:BROSSEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1299 PARKWAY DR STE D
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-3491
Mailing Address - Country:US
Mailing Address - Phone:919-394-0021
Mailing Address - Fax:
Practice Address - Street 1:1299 PARKWAY DR STE D
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-3491
Practice Address - Country:US
Practice Address - Phone:919-394-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer