Healthcare Provider Details

I. General information

NPI: 1649208166
Provider Name (Legal Business Name): CARY LYNN BERTHELOT MA, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SLU BOX 10845
HAMMOND LA
70402-0001
US

IV. Provider business mailing address

17274 RIVERSIDE LN
TICKFAW LA
70466-2846
US

V. Phone/Fax

Practice location:
  • Phone: 985-549-2351
  • Fax:
Mailing address:
  • Phone: 985-429-0096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberJ-000310
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: