Provider Demographics
NPI:1073969218
Name:BROUSSARD, CHARLES STEWART (LAC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:STEWART
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W PINHOOK RD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3290
Mailing Address - Country:US
Mailing Address - Phone:337-781-6467
Mailing Address - Fax:
Practice Address - Street 1:2020 W PINHOOK RD
Practice Address - Street 2:SUITE 402
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3290
Practice Address - Country:US
Practice Address - Phone:337-781-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA104101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)