Provider Demographics
NPI:1023572526
Name:BROUSSARD, NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6651 MAIN ST.
Mailing Address - Street 2:MC E. 1920
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:832-824-7012
Mailing Address - Fax:
Practice Address - Street 1:6651 MAIN ST.
Practice Address - Street 2:MC E. 1920
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:832-824-7012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX595671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical