Healthcare Provider Details

I. General information

NPI: 1003687583
Provider Name (Legal Business Name): KASSIE TANNEHILL LOTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 S FOURTH ST
JENA LA
71342-4084
US

IV. Provider business mailing address

109 DESPERADO RD
TROUT LA
71371-4501
US

V. Phone/Fax

Practice location:
  • Phone: 318-316-3020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number340116
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: