Provider Demographics
NPI:1053812982
Name:BROUSSARD, EBONI GRACE (MA, NCC)
Entity Type:Individual
Prefix:MS
First Name:EBONI
Middle Name:GRACE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3098 ASHBY DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1502
Mailing Address - Country:US
Mailing Address - Phone:404-409-1039
Mailing Address - Fax:
Practice Address - Street 1:3098 ASHBY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-1502
Practice Address - Country:US
Practice Address - Phone:404-409-1039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional