MEDICARE: CHARLI RHEA DEROUEN MS, LAC, CCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	3384	LA

General Provider Information

NPI Number	:	1447954631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLI RHEA DEROUEN MS, LAC, CCS

Provider Business Mailing Address
First Line	:	406 SAINT JULIEN AVE
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4622
Country	:	US
Telephone Number	:	337-366-6050
Fax Number	:

Provider Business Practice Location Address
First Line	:	406 SAINT JULIEN AVE
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4622
Country	:	US
Telephone Number	:	337-366-6050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2023
Last Update Date	:	03/30/2023

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