Basic Information
| Provider Information | |||||||||
| NPI: | 1861853590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROUSSARD | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | SEAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.A., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 MCDONALD ST APT 26O | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705068240 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1325 WRIGHT AVE STE D | ||||||||
| Address2: | |||||||||
| City: | CROWLEY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705262226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375145181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2016 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 7411 | LA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.