Healthcare Provider Details

I. General information

NPI: 1811670623
Provider Name (Legal Business Name): KALYN TEASETT TRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date: 09/25/2023
Reactivation Date: 10/03/2023

III. Provider practice location address

11607 SOUTHFORK AVE
BATON ROUGE LA
70816-5220
US

IV. Provider business mailing address

9853 WESTERLY AVE
BATON ROUGE LA
70814-4223
US

V. Phone/Fax

Practice location:
  • Phone: 504-641-4297
  • Fax:
Mailing address:
  • Phone: 225-572-0075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: