Provider Demographics
NPI:1205363918
Name:BROUSSARD, MELANIE CAVALIER
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:CAVALIER
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 1:1017 SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6711
Mailing Address - Country:US
Mailing Address - Phone:337-261-2300
Mailing Address - Fax:337-261-9080
Practice Address - Street 1:1017 SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-6711
Practice Address - Country:US
Practice Address - Phone:337-261-2300
Practice Address - Fax:337-261-9080
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101Y00000X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health