Provider Demographics
NPI:1720584360
Name:BROUSSARD, LAKESHA
Entity Type:Individual
Prefix:
First Name:LAKESHA
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 1:7305 HANCOCK VILLAGE DR STE 315
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-2771
Mailing Address - Country:US
Mailing Address - Phone:804-901-3458
Mailing Address - Fax:
Practice Address - Street 1:2545 BELLWOOD RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23237-4472
Practice Address - Country:US
Practice Address - Phone:804-625-9868
Practice Address - Fax:866-781-9646
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health