MEDICARE: LOUISIANA TELETHERAPY LLC

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1457980336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISIANA TELETHERAPY LLC

Provider Business Mailing Address
First Line	:	12072 GRIFFITH RD
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-6478
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12072 GRIFFITH RD
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-6478
Country	:	US
Telephone Number	:	225-715-9745
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MAGGIE DEVILLE
Credential	:	M.A.
Telephone Number	:	225-715-9745

Provider Enumeration Date	:	04/03/2020
Last Update Date	:	04/03/2020

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Directions to “LOUISIANA TELETHERAPY LLC ” Practice Location

Language	Start Address	Practice Location

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