Healthcare Provider Details

I. General information

NPI: 1346760972
Provider Name (Legal Business Name): GLENN LOUIS NAQUIN JR. LAC, NRP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 BLUE RIDGE DR
GRAY LA
70359-5318
US

IV. Provider business mailing address

264 BLUE RIDGE DR
GRAY LA
70359-5318
US

V. Phone/Fax

Practice location:
  • Phone: 985-262-7224
  • Fax:
Mailing address:
  • Phone: 985-262-7224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberLA14-95911
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1594
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: