Provider Demographics
NPI:1922358720
Name:BROUSSARD, LAUREN MICHELLE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:LAUREN
Middle Name:MICHELLE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:M
Other - Last Name:DEVOOGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-492-4550
Mailing Address - Fax:
Practice Address - Street 1:671 SW MAIN ST
Practice Address - Street 2:
Practice Address - City:WINSTON
Practice Address - State:OR
Practice Address - Zip Code:97496-6571
Practice Address - Country:US
Practice Address - Phone:541-492-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL109251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical