Provider Demographics
NPI:1952045338
Name:BROUSSARD, LISA K (LCSW008306)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LCSW008306
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-1600
Mailing Address - Country:US
Mailing Address - Phone:678-230-5164
Mailing Address - Fax:
Practice Address - Street 1:27 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-1600
Practice Address - Country:US
Practice Address - Phone:678-230-5164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALMSW009255101YM0800X
GACSW0083061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health