Provider Demographics
NPI:1275675043
Name:BROUSSARD, DINA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DINA
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MAMOU
Mailing Address - State:LA
Mailing Address - Zip Code:70554-4422
Mailing Address - Country:US
Mailing Address - Phone:337-468-5959
Mailing Address - Fax:337-468-5966
Practice Address - Street 1:1510 NAPOLEON ST
Practice Address - Street 2:
Practice Address - City:MAMOU
Practice Address - State:LA
Practice Address - Zip Code:70554-2320
Practice Address - Country:US
Practice Address - Phone:337-468-2333
Practice Address - Fax:337-468-3620
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA6039OtherLCSW LICENSE NUMBER