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General NPI Number Information
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NPI Number | 1952045338
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Entity Type | Individual
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Provider Name | LISA K BROUSSARD LCSW008306
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Gender | Female
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Dates
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Enumeration Date | 04/22/2022
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Last Update Date | 07/03/2023
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Provider Practice Location Address
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Address Line | 27 S MAIN ST
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City | JASPER
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State | GA
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Zip | 30143-1600
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Country | US
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Telephone | 678-230-5164
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Fax |
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Provider Business Mailing Address
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Address Line | 27 S MAIN ST
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City | JASPER
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State | GA
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Zip | 30143-1600
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Country | US
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Telephone | 678-230-5164
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LMSW009255
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW008306
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License Number State | GA
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