Provider Demographics
NPI:1225233646
Name:BROUSSARD, TAMMY (MS, LPC)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E CHOCTAW AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4604
Mailing Address - Country:US
Mailing Address - Phone:918-790-2292
Mailing Address - Fax:918-790-2291
Practice Address - Street 1:204 E CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-4604
Practice Address - Country:US
Practice Address - Phone:918-790-2292
Practice Address - Fax:918-790-2291
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3781101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200350940AMedicaid
12163359OtherCAQH #