Daniel Broussard – Clinical Social Worker

Key facts

NPI: 1053726554
Entity type: Individual (NPI type 1)
Primary specialty: Clinical Social Worker 1041C0700X
License: 111281 (CA)
Practice address: 11201 Benton St RM 1B-126
Loma Linda, CA 92357-9508
Phone: (909) 825-7084
NPI assigned: Jun 24, 2014
Sex: Male
Sole proprietor: No

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Corrections and Rehabilitation-Headquarters Pharmacy · Corona, CA · NPI 1578199741

NPD (past)
State of California Psychiatric Hospital · Corona, CA · NPI 1366783169

NPD (past)

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): No

State licenses

License	State	Type	Specialty
111281	CA	MD	Pediatric Dentist

Practice roles

Organization	Specialty	Status	New patients
Corrections and Rehabilitation-Headquarters		Past since Dec 1, 2022	Accepting new patients
State of California		Past since Dec 1, 2022	Accepting new patients

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Student in an Organized Health Care Education/Training Program	390200000X	111281	CA
Clinical Social Worker	1041C0700X	111281	CA	Yes

Addresses

Primary practice location

11201 Benton St RM 1B-126
Loma Linda, CA 92357-9508

Mailing address

11201 Benton St RM 1B-126
Loma Linda, CA 92357-1000
Phone (909) 825-7084

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Apr 4, 2025.

{
    "created_epoch": "1403568000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1743724800000",
    "number": "1053726554",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11201 BENTON ST RM 1B-126",
            "city": "LOMA LINDA",
            "state": "CA",
            "postal_code": "923571000",
            "telephone_number": "909-825-7084"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11201 BENTON ST RM 1B-126",
            "city": "LOMA LINDA",
            "state": "CA",
            "postal_code": "923579508",
            "telephone_number": "909-825-7084"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BROUSSARD",
        "first_name": "DANIEL",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-06-24",
        "last_updated": "2025-04-04",
        "certification_date": "2025-04-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "CA",
            "license": "111281",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "CA",
            "license": "111281",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Loma Linda, CA

All providers in Loma Linda, CA · Clinical Social Worker in California

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 4, 2025. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.