Provider Demographics
NPI:1699398966
Name:BROOMFIELD, DAISHA
Entity Type:Individual
Prefix:
First Name:DAISHA
Middle Name:
Last Name:BROOMFIELD
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 1:710 VERSAILLES BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2351
Mailing Address - Country:US
Mailing Address - Phone:318-449-4474
Mailing Address - Fax:
Practice Address - Street 1:710 VERSAILLES BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2351
Practice Address - Country:US
Practice Address - Phone:318-449-4474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health