Provider Demographics
NPI:1972964542
Name:BROUSSARD, DARYN (LPC)
Entity type:Individual
Prefix:MR
First Name:DARYN
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 POLEMAN RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-3206
Mailing Address - Country:US
Mailing Address - Phone:318-564-6636
Mailing Address - Fax:
Practice Address - Street 1:2924 KNIGHT ST STE 434
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2413
Practice Address - Country:US
Practice Address - Phone:318-631-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4156101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health