Provider Demographics
NPI:1295273837
Name:CINDERELLA BROUSSARD LLC
Entity type:Organization
Organization Name:CINDERELLA BROUSSARD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CINDERELLA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:337-886-3151
Mailing Address - Street 1:PO BOX 913
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-0913
Mailing Address - Country:US
Mailing Address - Phone:337-886-3151
Mailing Address - Fax:
Practice Address - Street 1:208 W GLORIA SWITCH RD # 6
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-3409
Practice Address - Country:US
Practice Address - Phone:337-565-7026
Practice Address - Fax:855-832-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2020-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09099363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty