Provider Demographics
NPI:1457679482
Name:BROUSSARD, PRISCILLA NA (LAC)
Entity Type:Individual
Prefix:MS
First Name:PRISCILLA
Middle Name:NA
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 SAPPHIRE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9079
Mailing Address - Country:US
Mailing Address - Phone:252-830-7540
Mailing Address - Fax:
Practice Address - Street 1:2808 S CROATAN HWY
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-9024
Practice Address - Country:US
Practice Address - Phone:252-441-2324
Practice Address - Fax:252-441-1994
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1475101YA0400X
LA1348101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)