Provider Demographics
NPI:1598287385
Name:BROUSSARD, SHAMEKA N (LCSW)
Entity Type:Individual
Prefix:
First Name:SHAMEKA
Middle Name:N
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 1:14507 DEVOUT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-6603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6243 W INTERSTATE 10
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-2086
Practice Address - Country:US
Practice Address - Phone:210-293-0883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX527841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical