Provider Demographics
NPI:1639467020
Name:BROUSSEAU, SUSAN L (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:BROUSSEAU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MCGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:24 STONE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5209
Mailing Address - Country:US
Mailing Address - Phone:207-213-2161
Mailing Address - Fax:
Practice Address - Street 1:24 STONE ST STE 201
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5209
Practice Address - Country:US
Practice Address - Phone:207-213-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC144871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical