Provider Demographics
NPI:1427220144
Name:BROUSSARD, ANNA RENE
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:RENE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENE
Other - Middle Name:
Other - Last Name:BROUSSARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 24242
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283
Mailing Address - Country:US
Mailing Address - Phone:480-444-9075
Mailing Address - Fax:480-751-1020
Practice Address - Street 1:6625 S RURAL RD
Practice Address - Street 2:SUITE 111
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3717
Practice Address - Country:US
Practice Address - Phone:480-751-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-12927101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health