Healthcare Provider Details

I. General information

NPI: 1104324078
Provider Name (Legal Business Name): AUDRA LAYNE COOK ROLAND LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7982 BRANDON DR
BATON ROUGE LA
70809-1246
US

IV. Provider business mailing address

1958 WISTERIA ST
BATON ROUGE LA
70806-5342
US

V. Phone/Fax

Practice location:
  • Phone: 318-282-5254
  • Fax:
Mailing address:
  • Phone: 318-282-5254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12927
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: