Provider Demographics
NPI:1396566634
Name:BROUSSARD, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BROUSSARD
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 1:2016 DESLONDE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70117-4004
Mailing Address - Country:US
Mailing Address - Phone:337-257-0801
Mailing Address - Fax:
Practice Address - Street 1:4919 CANAL ST STE 203
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5878
Practice Address - Country:US
Practice Address - Phone:504-483-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18754104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker