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General NPI Number Information
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NPI Number | 1003946500
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Entity Type | Individual
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Provider Name | SUSAN ANN BROUSSARD M.A
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Gender | Female
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 03/22/2016
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Provider Practice Location Address
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Address Line | 26323 JEFFERSON AVE E111
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City | MURRIETA
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State | CA
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Zip | 92562-9514
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Country | US
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Telephone | 619-607-1234
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Fax |
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Provider Business Mailing Address
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Address Line | 35748 EMILY AVE
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City | MURRIETA
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State | CA
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Zip | 92563-7404
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Country | US
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Telephone | 619-453-9915
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 49224
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License Number State | CA
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