Individual
LISA K BROUSSARD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCSW008306
Contact information
Practice address
27 S MAIN ST, JASPER, GA 30143-1600
(678) 230-5164
Mailing address
27 S MAIN ST, JASPER, GA 30143-1600
(678) 230-5164
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
LMSW009255
GA
1041C0700X
Clinical Social Worker
Primary
CSW008306
GA
Other
Enumeration date
04/22/2022
Last updated
07/03/2023
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