Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003112574 |
---|---|
Provider Name | Frederick Djuan Broussard |
First Address | Long Beach, CA 90807-4320 |
Second Address | Long Beach, CA 90807-4320 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2011 |
Last Update Date | 01/02/2011 |