Healthcare Provider Details

I. General information

NPI: 1033006184
Provider Name (Legal Business Name): BAYOU ROOTS THERAPY COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2025
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 HEYMANN BLVD STE 14
LAFAYETTE LA
70503-2397
US

IV. Provider business mailing address

PO BOX 55
GULF SHORES AL
36547-0055
US

V. Phone/Fax

Practice location:
  • Phone: 337-385-0405
  • Fax: 337-385-0405
Mailing address:
  • Phone: 337-278-0786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: LESLIE HERHOLD
Title or Position: OWNER
Credential:
Phone: 337-278-0786