Provider Demographics
NPI:1871117788
Name:BROUSSARD, PAUL D (LCDC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E GRAND ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWRIGHT
Mailing Address - State:TX
Mailing Address - Zip Code:75491-2303
Mailing Address - Country:US
Mailing Address - Phone:469-364-4601
Mailing Address - Fax:
Practice Address - Street 1:505 E GRAND ST
Practice Address - Street 2:
Practice Address - City:WHITEWRIGHT
Practice Address - State:TX
Practice Address - Zip Code:75491-2303
Practice Address - Country:US
Practice Address - Phone:903-227-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15230101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)