Active NPI
Dominique Broussard
- Psychologist
- San Francisco, CA
National Provider Identifier
1407431224
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 32386
- Practice address
- 2130 Fulton St.
San Francisco, CA 94117 - Phone
- (510) 610-9599
- NPI assigned
- Mar 12, 2021
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 32386 | CA | Primary |
Addresses
Primary practice location
2130 Fulton St.
San Francisco, CA 94117
Mailing address
4096 Piedmont Ave # 191
Oakland, CA 94611-5221
Phone (510) 610-9599
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1615507200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1615507200000",
"number": "1407431224",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4096 PIEDMONT AVE # 191",
"city": "OAKLAND",
"state": "CA",
"postal_code": "946115221",
"telephone_number": "510-610-9599"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2130 FULTON ST.",
"city": "SAN FRANCISCO",
"state": "CA",
"postal_code": "94117",
"telephone_number": "510-610-9599"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BROUSSARD",
"first_name": "DOMINIQUE",
"name_prefix": "Dr.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2021-03-12",
"last_updated": "2021-03-12",
"certification_date": "2021-02-19",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "CA",
"license": "32386",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Francisco, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.