MEDICARE: MS. LAMYA BROUSSARD LSW, MSS, MLSP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	SW138823	PA

General Provider Information

NPI Number	:	1639870157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAMYA BROUSSARD LSW, MSS, MLSP

Provider Business Mailing Address
First Line	:	191 PRESIDENTIAL BLVD STE W10
Second Line	:
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-1205
Country	:	US
Telephone Number	:	267-689-7877
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 PRESIDENTIAL BLVD STE W10
Second Line	:
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-1205
Country	:	US
Telephone Number	:	267-689-7877
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2023
Last Update Date	:	03/17/2023

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