Provider Demographics
NPI:1841172855
Name:BROUSSARD, MONIQUE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WATER MILL
Mailing Address - State:NY
Mailing Address - Zip Code:11976-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:760 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WATER MILL
Practice Address - State:NY
Practice Address - Zip Code:11976-2600
Practice Address - Country:US
Practice Address - Phone:347-754-7952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-22
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No171400000XOther Service ProvidersHealth & Wellness Coach
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst