Healthcare Provider Details

I. General information

NPI: 1164443818
Provider Name (Legal Business Name): MICHAEL DOUGLAS DE MAHY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 AUDUBON BLVD STE 206B
LAFAYETTE LA
70503-2600
US

IV. Provider business mailing address

401 AUDUBON BLVD STE 206B
LAFAYETTE LA
70503-2600
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 Code103TC1900X
TaxonomyCounseling Psychologist
License Number406
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: