Healthcare Provider Details

I. General information

NPI: 1952863243
Provider Name (Legal Business Name): IAN MATTHEW DERMODY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 HECTOR AVE STE A
GRETNA LA
70056-2548
US

IV. Provider business mailing address

252 HECTOR AVE STE A
GRETNA LA
70056-2548
US

V. Phone/Fax

Practice location:
  • Phone: 504-435-1444
  • Fax: 504-372-2775
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6759
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: