Provider Demographics
NPI:1609305952
Name:BROUSSARD, STEPHANIE BROADNAX (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:BROADNAX
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:BROADNAX
Other - Last Name:BROUSSARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:3410 WORTH ST STE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2092
Practice Address - Country:US
Practice Address - Phone:214-370-1000
Practice Address - Fax:214-370-1986
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57261104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker