Healthcare Provider Details

I. General information

NPI: 1962365189
Provider Name (Legal Business Name): LAWANDA RUBY MAE OTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2439 MANHATTAN BLVD STE 207
HARVEY LA
70058-5361
US

IV. Provider business mailing address

7021 CHATELAIN DR
NEW ORLEANS LA
70128-2591
US

V. Phone/Fax

Practice location:
  • Phone: 504-364-8949
  • Fax:
Mailing address:
  • Phone: 225-266-0933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: