Provider Demographics
NPI:1689226532
Name:BROUSSARD, WYANICKA
Entity Type:Individual
Prefix:
First Name:WYANICKA
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5144 E SAM HOUSTON PKWY N STE 114
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-3225
Mailing Address - Country:US
Mailing Address - Phone:346-327-5161
Mailing Address - Fax:
Practice Address - Street 1:5144 E SAM HOUSTON PKWY N STE 114
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-3225
Practice Address - Country:US
Practice Address - Phone:346-327-5161
Practice Address - Fax:186-693-6453
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty