Provider Demographics
NPI:1790953180
Name:BROUSSARD, CONNIE PEARL (LCSW, LMSW)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:PEARL
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LCSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 DULLES DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3008
Mailing Address - Country:US
Mailing Address - Phone:337-262-5870
Mailing Address - Fax:337-262-1272
Practice Address - Street 1:302 DULLES DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3008
Practice Address - Country:US
Practice Address - Phone:337-262-5870
Practice Address - Fax:337-262-1272
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALMSW 91241041C0700X
LALCSW 9124101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical