Provider Demographics
NPI:1962097063
Name:BROUSSARD, BIANCA LA'LONNIE CAROL
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:LA'LONNIE CAROL
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30800 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5925
Mailing Address - Country:US
Mailing Address - Phone:216-591-0324
Mailing Address - Fax:216-591-0324
Practice Address - Street 1:30800 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5925
Practice Address - Country:US
Practice Address - Phone:216-591-0324
Practice Address - Fax:216-591-0324
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.175497101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty