Healthcare Provider Details

I. General information

NPI: 1649131376
Provider Name (Legal Business Name): SHELBY FONTENOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 JAMES COMEAUX RD STE B, BOX 818
LAFAYETTE LA
70508-3376
US

IV. Provider business mailing address

139 JAMES COMEAUX ROAD STE B BOX 818
LAFAYETTE LA
70508-3376
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax: 772-675-9100
Mailing address:
  • Phone: 855-832-6727
  • Fax: 772-675-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberL-1050
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: