Healthcare Provider Details

I. General information

NPI: 1942533864
Provider Name (Legal Business Name): NORTHLAKE NEUROREHAB CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 LOUIS PRIMA DR SUITE A
COVINGTON LA
70433-5903
US

IV. Provider business mailing address

60 LOUIS PRIMA DR SUITE A
COVINGTON LA
70433-5903
US

V. Phone/Fax

Practice location:
  • Phone: 985-809-0929
  • Fax: 985-809-0223
Mailing address:
  • Phone: 985-809-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number501
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1574
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1574
License Number StateLA

VIII. Authorized Official

Name: DR. RAFAEL FRANCISCO SALCEDO
Title or Position: NUEROPSYCHOLOGIST
Credential: PH.D
Phone: 985-809-0929