Healthcare Provider Details

I. General information

NPI: 1609818418
Provider Name (Legal Business Name): LYLE LANNING LECORGNE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 AUDUBON BLVD SUITE 206-B
LAFAYETTE LA
70503-2676
US

IV. Provider business mailing address

401 AUDUBON BLVD SUITE 206-B
LAFAYETTE LA
70503-2676
US

V. Phone/Fax

Practice location:
  • Phone: 337-232-0060
  • Fax: 337-232-0062
Mailing address:
  • Phone: 337-232-0060
  • Fax: 337-232-0062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number365
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: