Provider Demographics
NPI:1922607456
Name:BROUSSARD, STEVEN NELSON II (BA, CADC-DP)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:NELSON
Last Name:BROUSSARD
Suffix:II
Gender:M
Credentials:BA, CADC-DP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25057 WOODVALE DR N
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1213
Mailing Address - Country:US
Mailing Address - Phone:313-608-3233
Mailing Address - Fax:
Practice Address - Street 1:1685 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1242
Practice Address - Country:US
Practice Address - Phone:248-525-6832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI156F00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No156F00000XEye and Vision Services ProvidersTechnician/Technologist