Provider Demographics
NPI:1871050146
Name:BROUSSARD, KELLY MICHELLE (LMHC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7006 W BRIARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-2928
Mailing Address - Country:US
Mailing Address - Phone:808-238-9990
Mailing Address - Fax:808-865-2930
Practice Address - Street 1:190 KEAWE ST STE 33
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2849
Practice Address - Country:US
Practice Address - Phone:808-238-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMHC-790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health