Individual
TAMMY BROUSSARD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.S., LPC
Contact information
Practice address
204 E CHOCTAW AVE, SALLISAW, OK 74955-4604
(918) 790-2292
(918) 790-2291
Mailing address
204 E CHOCTAW AVE, SALLISAW, OK 74955-4604
(918) 790-2292
(918) 790-2291
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
3781
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12163359
CAQH #
—
05
—
200350940A
—
OK
Enumeration date
06/16/2007
Last updated
07/16/2012
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