Healthcare Provider Details

I. General information

NPI: 1053726554
Provider Name (Legal Business Name): DANIEL BROUSSARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST RM 1B-126
LOMA LINDA CA
92357-9508
US

IV. Provider business mailing address

11201 BENTON ST RM 1B-126
LOMA LINDA CA
92357-1000
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 909-825-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111281
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number111281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: