Healthcare Provider Details

I. General information

NPI: 1538129408
Provider Name (Legal Business Name): PHYSICAL THERAPY CLINIC OF LAFAYETTE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 S COLLEGE RD
LAFAYETTE LA
70503-2912
US

IV. Provider business mailing address

1432 S COLLEGE RD
LAFAYETTE LA
70503-2912
US

V. Phone/Fax

Practice location:
  • Phone: 337-232-7080
  • Fax: 337-237-2517
Mailing address:
  • Phone: 337-232-7080
  • Fax: 337-237-2517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. KRISTINE ANNE BLACKWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 337-232-7080