Healthcare Provider Details

I. General information

NPI: 1063854750
Provider Name (Legal Business Name): LSU SPEECH, LANGUAGE AND HEARING CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 HATCHER HL LSU DEPARTMENT OF COMMUNICATION SCIENCES AND DISORDERS
BATON ROUGE LA
70803-0001
US

IV. Provider business mailing address

63 HATCHER HL LSU DEPARTMENT OF COMMUNICATION SCIENCES AND DISORDERS
BATON ROUGE LA
70803-0001
US

V. Phone/Fax

Practice location:
  • Phone: 225-578-9054
  • Fax: 225-578-2995
Mailing address:
  • Phone: 225-578-9054
  • Fax: 225-578-2995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2717
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3473
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4342
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5440
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1717
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5845
License Number StateLA
# 7
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5254
License Number StateLA

VIII. Authorized Official

Name: MRS. WENDY JUMONVILLE
Title or Position: CLINIC DIRECTOR
Credential: CCC-A
Phone: 225-578-9054