Healthcare Provider Details

I. General information

NPI: 1487707477
Provider Name (Legal Business Name): SUE A. MAYES PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 PARK RD
KINDER LA
70648-5306
US

IV. Provider business mailing address

509 PARK RD
KINDER LA
70648-5306
US

V. Phone/Fax

Practice location:
  • Phone: 337-738-2378
  • Fax: 337-738-5850
Mailing address:
  • Phone: 337-738-2378
  • Fax: 337-738-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP. T. A1961G
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: