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General NPI Number Information
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NPI Number | 1871050146
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Entity Type | Individual
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Provider Name | KELLY MICHELLE BROUSSARD LMHC
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Gender | Female
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Dates
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Enumeration Date | 02/22/2019
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Last Update Date | 10/03/2024
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Provider Practice Location Address
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Address Line | 190 KEAWE ST STE 33
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City | HILO
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State | HI
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Zip | 96720-2849
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Country | US
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Telephone | 808-238-9990
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Fax |
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Provider Business Mailing Address
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Address Line | 7006 W BRIARWOOD AVE
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City | WICHITA
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State | KS
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Zip | 67212-2928
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Country | US
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Telephone | 808-238-9990
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Fax | 808-865-2930
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MHC-790
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License Number State | HI
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