Healthcare Provider Details

I. General information

NPI: 1841970407
Provider Name (Legal Business Name): CRYSTAL BROUSSARD PHD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 NURSERY AVE
METAIRIE LA
70005-1732
US

IV. Provider business mailing address

1512 NURSERY AVE
METAIRIE LA
70005-1732
US

V. Phone/Fax

Practice location:
  • Phone: 888-399-0258
  • Fax:
Mailing address:
  • Phone: 504-250-1671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC25717
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1143502
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200004562
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16553
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12125
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13190
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC25717
License Number StateME
# 8
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number904019569
License Number StateVA
# 9
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW04770
License Number StateRI
# 10
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104033
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: