Healthcare Provider Details

I. General information

NPI: 1265976930
Provider Name (Legal Business Name): RANDY FONTENOT COUNSELING & CONSULTING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5329 DIJON DR SUITE 105
BATON ROUGE LA
70808-4378
US

IV. Provider business mailing address

5329 DIJON DR SUITE 105
BATON ROUGE LA
70808-4378
US

V. Phone/Fax

Practice location:
  • Phone: 225-276-8428
  • Fax:
Mailing address:
  • Phone: 225-276-8428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2810
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1178
License Number StateLA

VIII. Authorized Official

Name: MR. RANDY FONTENOT
Title or Position: MANAGER
Credential: LPC, LMFT
Phone: 225-276-8428