Healthcare Provider Details

I. General information

NPI: 1780237149
Provider Name (Legal Business Name): AIMEE BROUSSARD LOPEZ MOT, LOTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 ENERGY PKWY
LAFAYETTE LA
70508-3818
US

IV. Provider business mailing address

103 BAKER ST
BROUSSARD LA
70518-5417
US

V. Phone/Fax

Practice location:
  • Phone: 337-504-4244
  • Fax:
Mailing address:
  • Phone: 337-258-5883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number307044
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: