Healthcare Provider Details

I. General information

NPI: 1396391819
Provider Name (Legal Business Name): MYKAYLAN LEDET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 03/25/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11408 LAKE SHERWOOD AVE N STE A
BATON ROUGE LA
70816-0421
US

IV. Provider business mailing address

11408 LAKE SHERWOOD AVE N STE A
BATON ROUGE LA
70816-0421
US

V. Phone/Fax

Practice location:
  • Phone: 225-261-7143
  • Fax:
Mailing address:
  • Phone: 225-261-7143
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: