Provider Demographics
NPI:1285384636
Name:BROUSSARD MARRIAGE & FAMILY THERAPY INC
Entity type:Organization
Organization Name:BROUSSARD MARRIAGE & FAMILY THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:619-607-1234
Mailing Address - Street 1:29042 SILVERDALE LN
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-9616
Mailing Address - Country:US
Mailing Address - Phone:619-607-1234
Mailing Address - Fax:951-527-1401
Practice Address - Street 1:41661 ENTERPRISE CIR N STE 111
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5629
Practice Address - Country:US
Practice Address - Phone:619-607-1234
Practice Address - Fax:951-527-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-28
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty