Healthcare Provider Details

I. General information

NPI: 1134919137
Provider Name (Legal Business Name): KATHERINE LYNN BROUSSEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 NUGGETT ST
LOS ALAMOS NM
87544-2922
US

IV. Provider business mailing address

113 AZURE DR
WHITE ROCK NM
87547-3506
US

V. Phone/Fax

Practice location:
  • Phone: 505-412-2961
  • Fax:
Mailing address:
  • Phone: 505-412-9045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2026-0086
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: