Provider Demographics
NPI:1255833661
Name:BROUSSARD, MARK SHANNON (LAC, CCS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SHANNON
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:LAC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 PERKINS RD STE A
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-6200
Mailing Address - Country:US
Mailing Address - Phone:225-924-3000
Mailing Address - Fax:225-924-3030
Practice Address - Street 1:5431 SUPERIOR DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-6044
Practice Address - Country:US
Practice Address - Phone:225-964-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA661101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty